COLUMBIA LIBRARIES OFFSITE HEALTH SCIENCES STANDARD 1 ! WMM \ I "ill: TOD^\ (Eulumbta Intttermty hi tlie (City nf Nnit fork Ctullrrir of $Il)ijsiriaus anil g>«rrirmts l&tUxmtt Htbrary Digitized by the Internet Archive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/systemofpracticaOOberg LIST OF CONTRIBUTORS TO THIRD VOLUME. BORCHARDT, DR. M. FRIEDRICH, PROF. DR. P. L. HOFFA, PROF DR. A. HOFMEISTER, PROF. DR. F. NASSE, PROF. DR. D. REICHEL, OBERARZT DR. P. SCHREIBER, OBERARZT DR. A. WILMS, PRIVAT-DOCENT DR. M. A SYSTEM OP PRACTICAL SURGERY. BY Prof. E. von BERGMANN, M.D., Prof. P. von BRUNS, M.D., OF BERLIN, OF TUBINGEN, AND Prof. J. von MIKULICZ, M.D., OF BREST, AT'. VOLUME III. TRANSLATED AND EDIT E D B Y WILLIAM T. BULL, M.D., PROFESSOR OF SURGERY, COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK, JOHN B. SOLLEY, M.D., NEW YORK. SURGERY OF THE EXTREMITIES. LEA BROTHERS & CO., NEW YORK AND PHILADELPHIA. 1904. Entered according to Act of Congress, in the year 1904, by LEA BROTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. WESTCOTT & THOMSON. WILLIAM J. DORNAN, ELECTROTYPERS. PHILADA. PRINTER. PHILADA. CONTENTS. MALFORMATIONS, INJURIES, AND DISEASES OF THE SHOULDER AND UPPER ARM. CHAPTER I. PAGE Malformations and Injuries of the Shoulder ..... 17 CHAPTER II. Diseases of the Shoulder . . . . . . . . . 78 CHAPTER III. Operations on the Shoulder ........ 104 CHAPTER IV. Malformations of the Upper Arm . . . . . . .117 CHAPTER V. Injuries of the Upper Arm . . . . . . . . .118 CHAPTER VI. Diseases of the Upper Arm ........ 143 CHAPTER VII. Operations on the Upper Arm . . . . . . . .156 MALFORMATIONS, INJURIES, AND DISEASES OF THE ELBOW AND FOREARM. CHAPTER VIII. Defects of the Forearm and Malformations of the Elbow-joint . .163 CHAPTER IX. Injuries of the Elbow-joint ........ 166 (v) 362177 v i CONTENTS. CHAPTER X. PAGE Diseases of the Elbow-joint ........ 210 CHAPTER XI. Operations on the Elbow-joint ........ 222 CHAPTER XII. Malformations, Injuries, and Diseases of the Skin and Soft Parts of the Elbow and Forearm ........ 229 CHAPTER XIII. Malformations of the Bones of the Forearm ..... 243 CHAPTER XIV. Injuries of the Bones of the Forearm ...... 247 CHAPTER XV. Diseases of the Bones of the Forearm ...... 255 CHAPTER XVI. Operations on the Elbow and Forearm ...... 259 CHAPTER XVII. Accident and Judgment ......... 263 MALFORMATIONS, INJURIES, AND DISEASES OF THE WRIST AND HAND. CHAPTER XVIII. Malformations of the Hand Excepting the Congenital Contractures 270 CHAPTER XIX. Injuries of the Wrist and Hand . . . . . • • 279 CHAPTER XX. Diseases of the Wrist and Hand ....... 321 CHAPTER XXI. ■ Operations on the Wrist and Hand ....... 374 CONTEXTS. vii MALFORMATIONS, INJURIES, AND DISEASES OF THE HIP AND THIGH. CHAPTER XXII. PAGE Malformations of mi: Hip-joint 389 CHAPTER XX1I1. Injuries of the Hip .......... 416 CHAPTER XXIV. Diseases of the Hip .......... 452 CHAPTER XXV. Operations at the Hip. ......... 524 CHAPTER XXVI. Deformities of the Thigh ......... 530 CHAPTER XXVII. Injuries of the Thigh . . . . . . . . . , 532 CHAPTER XXVIII. Diseases of the Thigh ......... 549 CHAPTER XXIX. Operations ox the Thigh 559 INJURIES AND DISEASES OF THE KNEE AND LEG. CHAPTER XXX. Injuries of the Knee .......... 565 CHAPTER XXXI. Diseases in and About the Kxee-joint ...... 594 CHAPTER XXXII. Malformations of the Leg ......... 669 CHAPTER XXXIII. Injuries of the Leg .......... 671 v iii CONTENTS. CHAPTER XXXIV. PAGE Diseases of the Leg .......... 684 CHAPTER XXXV. Operations on the Leg ......... 713 MALFORMATIONS, INJURIES, AND DISEASES OF THE ANKLE AND FOOT. CHAPTER XXXVI. Congenital Malformations of the Foot (Except Congenital Con- tractures) ........... 722 CHAPTER XXXVII. Injuries of the Ankle and Foot ....... 728 CHAPTER XXXVIII. Diseases of the Ankle and Foot ....... 773 CHAPTER XXXIX. Operations on the Foot and its Joints ...... 873 MALFORMATIONS. INJURIES, AND DISEASES OF THE SHOULDER AND UPPER ARM. By Obekakzt Dr. A. SCHREIBEB \xd Prof. Dr. F. HOFMEISTER. CHAPTER I. MALFORMATIONS AND INJURIES OF THE SHOULDER. CONGENITAL MALFORMATIONS. Congenital Defects of the Clavicle. — Congenital defects of the cla\icle are rare, and are observed as partial or complete absence of the bone, usually bilateral (Fig. 1). Sometimes medial rudiments from | to 2 inches long are still present, the shoulder being usually somewhat de- pressed. In the majority of cases the functional disturbance was only slight, so that the malformation was discovered by chance. Adduction, which is usually limited by the action of the trapezius and levator anguli scapula?, could be increased passively until the arms met upon the chest. Congenital Elevation of the Scap- ula (High Shoulder).— Of greater surgical interest is the congenital high position of the scapula. Described first by Eulenberg in 1863, this not infrequent affection received general attention only after Sprengel's treatise (1891), and since then, under the name of Sprengel's deformity, it has been the subject of numerous publi- cations, so that now more than 50 cases are recorded. The deformity, discovered usually in the first year, affects the male with greater fre- quency (21 to 16). Milo, Honsell, and Wittfield described cases of bilateral deformity. Up to the tenth year the Congenital absence of clavicle. (Gross. Vol. III.— 2 ( .17 ) 18 MALFORMATIONS AND INJURIES OF THE SHOULDER. amount of upward displacement of the scapula varies between \ and 2h inches; in older subjects between 1 and 4\ inches. Simultaneous rotation of the scapula has been seen, the lower angle approaching the middle line, rarely the reverse. In individual cases the upper angle, bent forward, has been falsely diagnosticated as an exostosis. Scoliosis of varying degree is a frequent accompaniment, likewise facial asym- metry, rarely other deformities. Functional disturbance was generally absent; in some cases abduction was impaired. Sprengel and most of the recent writers regard this elevation of the scapula as a deformity of intra-uterine origin (the result of insufficient amniotic fluid); recently Kausch demonstrated defects in the lower part of the trapezius and regarded them as responsible for the deformity. As to the treatment, the purely orthopaedic measures have been thus far without notable results. Various authors claim good results from division of the elevators of the scapula combined eventually with excision of the upper angle of the scapula. As a rule the slight functional dis- turbance makes treatment unnecessary. Instances of acquired high position of the shoulder following rhachitis have been described by Kolliker, Gross, and Bender. Congenital Dislocation of the Shoulder.— Congenital dislocation has also Keen seen. Smith reports subacromial dislocation of the clavicle. A large number of the cases described as congenital dislocation of the shoulder belong among the deformities of paralysis; still, numerous positive cases have been described: particularly those operated upon cannot be doubted. Phelps saw 6 cases and operated upon 4 of them. Tilden Brown was able in 1 case to reduce the head of the humerus after incising the capsule. Phelps, in the majority of instances, was obliged to remove a part of the capsule and part of the head. Blood- less reduction, subsequent to forcible extension and followed by fixation for several months, has been successful in a few instances. Dislocations of the shoulder (subcoracoid, subacromial, and infra- spinate — the latter more often bilateral) have been reported by R. Smith. The dislocation was usually discovered at a later period in childhood. The patients frequently showed other malformations (club- foot, etc.). In most of the cases there was marked atrophy of the muscles. In some the arm could only be swung backward and forward, abduction being impossible. The pathological specimens showed im- perfect development of the articular head and its cavity, the latter in some cases appearing displaced or having a poorly developed margin. The capsule was generally normal, the head of the humerus somewhat oval, the tuberosity separated from the joint surface by a broad, shallow groove, that is to say, the joint surface was only partially developed. (R. Smith.) INJURIES OF THE skis AND MUSCLES OF THE SHOULDER. J9 INJURIES OF THE SKIN AND MUSCLES OF THE SHOULDER. Avulsion of the skin of the shoulder is not infrequent as a result of street accidents and machinery injuries, and was formerly much dreaded on account of the subsequent contractures. 1 Especially on the axillary borders, if large skin areas are involved, surgeons attempt to prevent contraction by transplanting skin-flaps from the chest or back. Incised wounds of the muscles require suture as a rule if large. Subcutaneous rupture of individual muscles is observed at times. Rupture of the deltoid is reported by Sedillot, Arloing, and others, and Regard reports that of \'S2 cases of rupture 14 were of the deltoid. These ruptures occur usually in lifting heavy bodies, and rarely as the result of direct violence. The rupture is seldom complete, but the cleft in the substance of the muscle is easily recognized; this, together with the pain and the appearance of ecchymosis at the point of injury (the latter being usually about two inches above the insertion of the deltoid) makes the diagnosis simple, especially when an attempt to abduct the arm widens the palpable depression, and elevation is impossible. Rup- tures of the rotators, of the pectoralis, etc., are occasionally seen, but are void of any great practical importance. Rupture of the long tendon of the biceps will be described later under ruptures of the muscles of its group. Cases of so-called dislocation of the biceps tendon have been described by Cooper, Bromfield, Duverney, and Monteggia, which are open to doubt on anatomical grounds, as demonstrated by Schiiller, and by reason of the easy confusion of the symptoms as given with those of a joint sprain, or of bursitis subacromialis or subdeltoidea, as indicated by Jarjavay. Tilmann has recently called attention to the traumatic lesions of the trapezius and the importance of these hitherto disregarded affections. They result from pressure, a blow, or laceration involving the muscle, and often lead to functional disturbance of the arm that may last for years. As an important subjective symptom, Tilmann lays stress upon the pains which radiate into the arm and become localized in the region of the insertion of the deltoid. He distinguishes three varieties of the affection: 1. Impairment of the entire muscle, the scapula being rotated about its vertical and sagittal axes, the shoulder depressed and further from the middle line, the inner border more prominent during con- traction of the muscle, and the action of the trapezius weak. 2. Impair- ment of the lower, adductor portion, characterized by limited abduction, high position of the scapula, and increased distance from the middle line. 3. Impairment of the upper, levator portion, recognizable by the depression of the shoulder and rotation of the lower angle toward the middle line; movements of the arm free. 1 The term contracture is used in conformity with the later nomenclature, based upon the path- ology- and etiology of fixed positions of joints — e. g., cicatricial contraction of the skin over a joint produces a contracture of the joint. 20 MALFORMATIONS AND INJURIES OF THE SHOULDER. INJURIES OF THE VESSELS OF THE SHOULDER. Wounds of the shoulder are particularly dangerous if complicated by injuries of the large vessels of the neck or of the apex of the lung or pleura. The vessels lying under the clavicle and in the depth of the axilla are reached easiest by penetrating instruments. In gunshot- wounds the vessels may be struck by the projectile itself or be torn by splinters of bone or sharp fragments. Complete transverse division of a vessel by the projectile is rare; more frequently the vessel is opened laterally. The modern metal-coated bullets with their enormous pene- trating power cut like a knife through even the elastic arterial wall. The bullet-wounds, except the so-called " key-holers," are so small that they may be closed by the pressure of the adjacent tissues. MaeCormac saw a bullet-wound of the axillary artery so plugged by the musculo- cutaneous nerve that no bleeding occurred; it began only on retraction of the nerve, and necessitated ligation. In regard to the frequency of wounds of the vessels, the medical report of the Franco-Prussian War gives 30 cases of ligation of the subclavian (6 successful) and 28 of the axillary (13 successful). In the War of the Rebellion (in 878 cases of arterial hemorrhage in the upper extremities) the subclavian was ligated 51 times (10 successfully), the axillary 49 times (with a mortality of 85.7 per cent.). Simultaneous injury of artery and vein is not rare. In 13 punctured wounds Rotter found the vein involved 5 times. Kiittner emphasizes this fact, especially with reference to the modern small-calibre bullets. Arteriovenous aneurisms have been observed repeatedly in the region of the axillary vessels. Subcutaneous injuries of the large branches result from severe crushing forces which affect the artery directly; from violent tearing, if the arm is jerked backward or upward; or from the immediate action of frag- ments upon the vessel-wall in fractures of the upper part of the humerus or clavicle. Ziegler saw a transverse rupture of the subclavian due to comminuted fracture of the scapula, and explained it by overstretching, as the force had been exerted from behind forward, and the fragments were separated from the vessel by a thick muscular layer. Vascular injuries in dislocation of the shoulder have acquired a distinct notoriety. Rupture may result from the stretching and tearing of the vessel, pro- duced by the protruding articular head at the moment of dislocation or in the manipulation of reduction, from the breaking up of adhesions which have formed between the vessel and dislocated head. Spicules of bone and osteophytes can injure the vessel-wall, as is illustrated by the cases of Anger, Wutzer, Gibson, Roux, and others. Also splinters of bone from fractures complicating the dislocation can injure the vessel. Korte, who collected 53 cases, has shown that in about one-fifth of these the vessel was injured at the time of dislocation, more frequently, however, during reduction. Old dislocations present the greatest con- tingent, a fact easy to understand when it is considered how much TNJUBIES OF TIH-: VESSELS OF THE SHOULDER. 21 more force is required to reduce in old than in recent cases, and the more favorable conditions for the production of vascular injury given by cicatrices, adhesions, and new hone about the dislocated head. In considering the etiology of aneurisms following reduction of recent dislocations it must always be remembered thai the dislocated head can at the outset close the hole in the vessel, the blood being given an outlet for the first time at the moment of reposition. Forcible mobilization of a stiffened shoulder-joint may injure the vessels, particularly if inju- dicious abduction is employed. Paget and Korte each relate a case in which, during passive motion to overcome a contracture of the shoulder-joint following inflammation, the arm was suddenly elevated by accident, and in consequence a tear of the axillary artery resulted which led to the formation of an aneurism. The lesions produced in the vessel by blunt forces differ; most fre- quently a complete transverse rupture is seen, rarely round or oval holes, which in certain cases without doubt indicate avulsion of a lateral branch (subscapular artery, circumflex humeri). In some instances the force has been expended before producing complete separation; the intima and media are torn, but the adventitia remains intact. The torn inner coats curl up and become the starting-point of a more or less extensive thrombosis. Gangrene of the finger or arm may result. The process, which in this case is so ominous for the future of the limb, is, in strong contrast, a life-saving agency in cases of severe crushing and laceration, as by machinery or powder explosions (avulsion of arm). The involution of the intima checks the primary hemorrhage. Arrest of the circulation in an arterial trunk alone is not sufficient, however, to produce gangrene, otherwise it would be impossible to explain how ligation of the subclavian so seldom causes gangrene (3 out of 90, v. Bergmann), and indeed is able to check a beginning gangrene. Other factors must be concerned. Where the inner coats alone are ruptured, it is due to contusion of the surrounding parts (Herzog) ; in cases of complete rupture, as also in puncture and shot-wounds, where the narrowness and shortness of the wound prevent the blood from escaping outward, it is due to the enlarging hematoma and interstitial infiltration. The venous channels thus become compressed and the development of the collateral circulation is prevented. Moreover, v. During has demon- strated that resorption of fibrin-ferment by the walls of the small veins favors thrombosis of the veins still unaffected. The disturbances of innervation which follow injuries of the axillary vessels appear in the form of paresthesias in the distal portions of the limb, more or less severe neuralgic pains, or sensory and motor disturb- ances. If the plexus by its proximity to the injured vessel shares in the damage or is compressed by the extravasated blood, the pain begins at the time of the injury. It may develop gradually with the growth of the hematoma, in which case it usually disappears as the latter is absorbed, v. Bramann cites 3 cases of plexus involvement in 1G cases of injury of the subclavian, and 12 cases in 29 of injury of the axillary artery. 22 MALFORMATIONS AND INJURIES OF THE SHOULDER. Except for their effect upon the nutrition and innervation of the extremity, as described, the injuries of the large axillary vessels have the same symptoms and sequelae (primary and secondary hemorrhage, formation of aneurisms, suppuration of the hsematoma) as those of the vessels of the neck. The general discussion of the diagnosis and prognosis of injuries of the vessels presented by Jordan in Vol. II. applies here. A special point is that hrematomata and diffuse infiltra- tions of blood spread by predilection in the direction of the yielding axillary space, and may finally perforate beyond. If the subcutaneous bleeding continues for some time, the infiltration may spread over wide areas of arm and thorax. As to the prognosis, the available statistics, mostly old, present a tragic picture: total mortality (Pirogoff), 68.1 per cent.; mortality from secondary hemorrhage (Billroth), 81.2 per cent.; from punctured wounds (Thormann), 42.2 per cent.; from gunshot-wounds of the shoulder vessels (Schmidt), 60 to 70 per cent. To-day the prognosis of gunshot-injuries in particular may be regarded much more favorably, as founded upon recent war experiences. The introduction of small- calibre metal-coated bullets and the progress made in treatment have diminished the dangers of primary hemorrhage and subsequent septic hemorrhage. The percentage of resulting aneurisms, however, has increased. Injuries of the vessels associated with dislocation of the shoulder give an unfavorable prognosis. Of 53 cases related by Korte, 34 died — of these, 16 without operation, 8 after ligation of the sub- clavian, 7 after double ligation at the place of injury, 3 after amputa- tion at the shoulder; 18 recovered — of these, 6 without operation, 8 after ligation of the subclavian, 3 after double ligation at seat of injury, 1 after amputation at the shoulder. The general principles which are standard for wounds of the arteries are given in Vol. II. It has been repeatedly recommended to ligate the subclavian above the clavicle previous to ligation at the site of injury, as the latter is often difficult by reason of the extravasation of blood, or at least to pass a ligature around the vessel to be tied in case of necessity, as digital compression in the supraclavicular notch has often proved uncertain, particularly if hindered by thick cushions of fat, enlarged glands, or extravasation of blood. It is better still to make the entire trunk accessible by a longitudinal incision, temporary resec- tion of the clavicle, and separation of the fibres of the pectoralis major, as employed by Langenbeck and recently very generally approved. If the injury involves one of the branches, ligation of the trunk should be avoided if possible. In a case of avulsion of a branch (dislocation) Korte recently attempted lateral suture of the vessel. It held twenty- one days, but ligation of the axillary was necessitated by secondary hemorrhage. Large or rapidly increasing hsematomata (in subcutaneous injuries of the arteries or with obstruction of the flow toward the surface) demand operative interference: first, because the general dangers are thereby most quickly avoided; secondly, because the relaxation of the tissues by INJURIES OF THE NERVES OF THE SHOULDER. 23 removal of the extravasation improves the conditions for the collateral circulation and the venous circulation, and thereby prevents most effect- ually the threatening gangrene. The recognized liability of tissues infiltrated with blood to septic infection seems to connterindicate com- plete closure of wounds after such evacuation. Except in single instances of obstruction due to rupture of the inner coats of the artery, expectant treatment is indicated by spontaneous recovery in a compara- tively large percentage of eases. Warmth (Bryant) and moderate ele- vation are employed to increase the circulation, their continuance being counterindicated only by the appearance of gangrene or by associated injuries. INJURIES OF THE AXILLARY VEIN. Injuries of the axillary vein are much less frequent than those of the artery. They can be produced by the same causes and forces that damage the arteries. More frequently they are the result of operative procedures (removal of axillary glands), particularly if the vein is involved in the mass or has been drawn by adhesions toward it, so that the empty vessel is not recognized. Not infrequently injury of the vein is unavoidable and necessitates ligation and excision. Contusion of the vein by blunt forces (fractures, dislocations, shot-injuries) may produce thrombosis, although this is less frequent here than in the veins of the lower extremity. The danger of venous injuries lies not only in the bleeding, but especially, if the arm is lifted, in the possibility of air being sucked into the open subclavian. Secondary hemorrhage and pyaemia are also possible. (In regard to air-emboli, see Vol. II., page 56; on page 59 is described the general treatment of wounds of the veins, and on page 60 the injuries and ligation of the subclavian.) At the present time ligation of the axillary vein is of little significance, even if necessary above the junction of the cephalic vein. The slight stasis in the arm usually disappears spontaneously or after bandaging and elevating. INJURIES OF THE NERVES OF THE SHOULDER. All of the forces causing injuries of the vessels can produce lesions of the brachial plexus. Among the open injuries gunshot-wounds are most important. The modern metal-coated bullets rarely produce complete transverse division of the nerve-trunks. They graze more or less deeply or produce a sort of button-hole puncture. Among 260 nerve injuries Fischer gives 53 of the brachial plexus; among 57 Beck gives 15 of the brachial plexus, and among 16 Socin gives 7 of the brachial plexus. In the South-African War Kiittner and the English surgeons found that the brachial plexus was injured with remarkable frequency; it is explained by the prone position in warfare. 24 MALFORMATIONS AND INJURIES OF THE SHOULDER. Among the injuries due to blunt forces the most conspicuous are direct contusion of the supraclavicular region, evulsion of the arm during delivery, dislocation of the humerus, fracture of the clavicle, of the neck of the scapula, and of the humerus. Associated primary injuries of the nerves are usually the effect of contusion. Complete transverse division by blunt forces is extremely rare. Impalement by sharp fragments of bone is possible. In dislocation of the shoulder the circumflex nerve is injured more frequently than the main trunks of the plexus, and causes deltoid paralysis. Long-continued pressure or laceration can impair or destroy the function of the nerves as effectually as a single severe contusion. Pressure may be produced by lodged foreign bodies, the luxated head of the humerus, or displaced fragments of a fracture. There are a number of pressure-paralyses of the brachial plexus which are produced in part by "occupational injuries," in part by adventitious causes. Among them, the paralyses due to strap-pressure, seen in peddlers, etc.; stone-carriers' paralysis of Rieder; so also "crutch par- alysis," the so-called "sleep paralysis" (Saturday-night paralysis), and the so-called "narcosis paralysis" often observed after a protracted operation. Narcosis paralysis, which, naturally, is not due to the anaesthetic, is usually discovered on awakening from the anaesthesia. It varies from slight paresthesia and paresis to even complete sensory and motor paralysis affecting parts of or the entire plexus. The sensory area of the circumflex nerve is found unaffected with striking frequency. (Biklin- ger.) The paralysis is produced most often by elevation of the arm accompanied with backward depression of the shoulder, whereby the plexus is compressed between the clavicle and the first rib. (Budinger, Gaupp.) Braun refers it to pressure of the head of the humerus upon the nerves of the axilla. The use of shoulder-supports in the Tren- delenburg position can cause brachial paralysis. Secondary traumatic lesions of the plexus are produced by the pressure of cicatrices in or about the nerve, by the pressure of excessive callus against or around the nerve, and finally by an apparently infectious neuritis. The significance of arterial hsematomata in regard to the plexus has already been mentioned. Symptoms. — The symptoms of injuries of the plexus are classified as those of irritation and of paralysis. At the moment of injury (for example, in shot-wounds) a sudden excruciating, "lightning-like" pain is often described, at times followed by general shock. Later, pain may be absent and only a feeling of numbness persist. As in neuritis or as occasioned by the above-mentioned causes (foreign bodies, cicatrices, etc.), a constant irritation may persist and neuralgias develop which may extend over wide areas — in fact, radiate into the unaffected side of the body. Diagnosis. — For the diagnosis the paralyses are most important. For the details of the symptoms, which render possible the accurate locali- zation of the injury, the reader is referred to the text-books on nervous l\.jl'j:/j:s of tin: SERVES OF THE SHOULDER. 25 diseases. Moreover, the primary paralyses, especially in shot-wounds, are nol necessarily confined to the nerve-trunk immediately concerned, as Kiittner has recently demonstrated. He found total paralysis of the plexus in cases in which only a branch had been affected — in fait, where the nerve had not been touched — and explained it as the tele- kinetic action of penetrating projectiles of high velocity. Prognosis. — The prognosis of these plexus paralyses varies with the nature of the lesion. Complete division of the nerve is unfavorable, as suture of the plexus does not give the results obtained in the more distal nerve-trunks. Of (i rases of complete division of the plexus in the axilla with suture, in only 1 was the use of the hand after suture as good as that of the sound one (Etzold). The prognosis of modern shot-wounds, in which, as mentioned, complete division is rare, does not appear so unfavorable. The narcosis paralyses give a good prospect of complete recovery, even if a long period elapses before motion returns. The latter is first regained usually in the fingers and forearm. The prognosis of the "occupation" pressure-paralyses is usually also good. Ordinarily with the removal of the existing cause motion returns quickly. The paralysis following dislocation of the shoulder is to be regarded more unfavorably, for, although recovery follows speedily in the majority of cases, in many a rapid atrophy takes place or neuritis develops with violent attacks of pain. A particularly frequent observation is that of complete deltoid atrophy with lasting impairment of motion. In many cases mobility returns onlv after many weeks and months (in a case of Duplay's, after six months). Neuromata may form at the site of division of the plexus as a result of cicatricial adhesions. Not infrequently severe neuralgias occur later, also trophic disturbances. The prognosis of secondary nerve lesions is always doubtful. It depends upon whether the cause can be removed. Kiittner called attention to the possibility of extensive cicatricial processes developing within the nerve-trunk following gunshot-wounds and preventing functional repair. Treatment. — In the treatment of primary paralysis evidence of division of the nerve is conclusive. Where division is probable, according to the nature of the injury (incised and punctured wounds) suture of the nerve is indicated; where not probable, expectant treatment. This applies not only to subcutaneous injuries, but also especially to modern gunshot-wounds, as the nerve-trunks are not severed by them. For pressure-paralysis, the first therapeutic precept is removal of the cause. As the causes are numerous the treatment is equally varied: change of occupation, reduction of dislocations and fractures, operative removal of foreign bodies (bullets), bone splinters, projecting fragments, hsematomata, resection of the dislocated head. Nussbaum relieved a case of muscular contracture and sensory disturbance, clue to a blow of a musket, by stretching the nerves at the elbow and in the axilla and neck. In a child eleven years old Vogt freed the plexus from con- stricting callus by resecting the humerus. In secondary neuralgias and paralyses the decision in favor of opera- tive interference is made more quickly than in primary cases. Here 26 MALFORMATIONS AND INJURIES OF THE SHOULDER. one can count with some certainty upon an object for surgical attack — compressing cicatrices, callus — while, on the other hand, from the nature of these changes one can count but little upon spontaneous cure. The nerve is freed from the cicatrix or callus and placed in the healthiest tissues possible. It may be necessary to resect the portion of nerve injured by the cicatrix and to suture. Further, massage, electricity, and exercise should be employed in all cases whether operation is necessary or not. Various surgical procedures have been suggested to improve the function in incurable paralyses of individual muscles of the shoulder. In serratus paralysis Hecker suggests a bandage to prevent wing-like spreading of the scapulae. Gaupp restored the normal elevating capa- bility of the arms in bilateral paralysis of the trapezius (following oper- ation for cervical glands in which the accessorious was cut) by a sort of jacket which drew the shoulders backward. In a case of progressive muscular atrophy affecting chiefly the trapezii, Eiselsberg obtained a good result by suturing together the scapulae in the upper half and lengthening the clavicles. FRACTURES OF THE CLAVICLE. Fractures of the clavicle are among the most frequent bone fractures, constituting about 14 to 16 per cent. In children and young adults they are most common next to fractures of the radius. They occur most often in the first ten years of life, but may be produced in utero or during delivery. Gurlt, Bruns, and English statisticians give a relative frequency of 15 to 16 per cent., Malgaigne 10 per cent., Bardenheuer 13 per cent, and Pitha 18.7 per cent. In children the fracture occurs with about equal frequency in both sexes; Kronlein regards it as the equivalent of shoulder luxation in the adult. In adults it is more common in males (4 to 1). Bilateral fractures are rare. Fig. 2. Infraction of the clavicle, (v. Bruns.) One distinguishes between fractures complete and incomplete (infrac- tion); single or multiple; typical inflexion and torsion breaks; and in reference to the seat, fractures of the acromial, middle and sternal third, and of the epiphysis and shaft. In about one-third of the cases the break is oblique and situated at the junction of the middle and outer third. Fracture of the inner third is rare, also of the epiphysis. The acromial end has no epiphysis. FRACTURES OF THE CLAVICLE. 27 Etiology. — The cause is usually indirect violence, as by falling upon the hand with the elbow and shoulder fixed. The force is thus trans- mitted to the clavicle, which is forced firmly against the sternum; its S curve is increased and the hone breaks at the weakest point, the junction of the middle and outer third. It may he due to muscular action, as in raising the arm, and is favored by pathological processes. It can also result if the bone is depressed so that the first rib acts as a fulcrum, or by forcible compression of the shoulders, as between a wagon and a wall, etc. By direct violence the break may occur at any point, as by a blow, fall, recoil of a gun, etc., but is usually at the exposed outer third. The line of fracture is commonly oblique, agreeing with the mechanism of production. Transverse fractures are seen in children. Double and Fig. 3. Fracture of the clavicle. (Anger.) comminuted fractures by direct violence, except from gunshot-wounds, are rare. Compound fractures are exceptional in spite of the super- ficial position of the bone. Complications involving the adjacent large vessels and nerve-trunks, the pleura, and lung apices are equally in- frequent. Symptoms and Diagnosis. — Fractures of the middle third present a characteristic symptom-complex, dominated by the typical dislocation resulting from the combined effect of muscular traction and the weight of the arm. The latter depresses the shoulder and attached outer fragment, while the pectorals draw the same toward the middle line and 28 MALFORMATIONS AND INJURIES OF THE SHOULDER. forward. The proximal fragment is drawn upward by the sternocleido- mastoid, so the outer is pushed under the inner fragment, and together they form an upturned angle. At times the displacement is so marked that the fragments form a T or Y. The shortening by displacement is easily verified by comparative measurement of the distance between the acromion and the sternoclavicular articulation on the two sides. In transverse fractures the displacement is usually less or altogether absent. The same applies to subperiosteal fractures and infractions in childhood, where often little if any irregularity is demonstrable. With marked dis- placement the outlines of the inner fragment are easily palpable through the skin and often visible. By grasping the two fragments, or in children, where the outer fragment is small, by seizing the shoulder firmly, and moving the fragments upon each other, false motion and crepitation are usually obtainable. The symptom-complex is complete when to this direct evidence are added the accessory signs — e. g., swelling and ecchymosis at the point of fracture, the inclination of the head Fig. 4. Fracture of the clavicle; union with deformity, (v. Bruns.) toward the affected side to relax the sternocleidomastoid, and finally the inability to raise the arm. The latter is due to the pain, which may be overcome by irritating the fracture surfaces. The diagnosis in adults is thus simple. In children fracture or infraction of the clavicle will not be overlooked if the rule is always followed to ascertain the condition of the clavicle whenever a child complains of pain in the arm and will not move it voluntarily. If doubt still exists after the first examination, it will be cleared up in a few days by the appearance of a circumscribed spindle-shaped swelling, the beginning formation of callus. In fractures of the outer third the displacement depends upon whether the break occurs at or to the outer side of the coracoclavieular ligament. Fractures near the trapezoid and rhomboid ligaments cause little dis- placement. (R. Smith.) Fractures beyond this usually allow the inner end of the outer fragment to be tilted up by the trapezius, while the inner fragment is drawn down and inward by the muscles attached to its under surface. Consequently considerable angular displacement FRACTURES OF THE CLAVICLE. 29 — in fact, to a right angle — is possible. Fractures near the acromial end may resemble a supra-acromial dislocation; but the localized tender- ness, the irregular contour of the surfaces, the crepitus, and accurate measurement of the distance from the edge of the acromion to the projecting edge of the fracture — which is greater than the width of the acromion — will prevent mistake. In the infrequent fractures of the inner third, displacement is usually prevented by the costoclavicular Ligament below and the sternocleidomastoid muscle above. Prognosis. — The prognosis of fractures of the clavicle is usually favorable. Union occurs in children in from two to three weeks, in adults in from three to five weeks — an average of twenty-eight days Fig. 5. Modified Velpeau bandage. according to Gurlt; and even a persisting deformity usually does not essentially impair the function of the arm. Only union with marked displacement can cause any material loss of function. Pseudo- arthrosis is rare and occurs almost exclusively in the middle third. It does not seem to cause any impairment. Callus uniting the clavicle to the coracoid process or to the rib may hinder abduction permanently. Pressure of the callus or of a displaced fragment has been known to produce neuralgic pains and even paralysis in the course of the brachial plexus. The disability due to functional disturbances — atrophy of the muscles, etc. — may reach a high grade, 10 to 50 per cent. Becker saw a case weakened 50 per cent, in working ability by bilateral fracture of the clavicle. (See chapter on Accidents and Judgments.) 30 MALFORMATIONS AND INJURIES OF THE SHOULDER. Treatment. — If the displacement is slight — as in infraction — a simple sling is sufficient; massage hastens union. Dagron reports the benefits of massage in 20 cases. In all fractures with displacement reduction is indicated at the outset. This is effected by standing behind the sitting patient and — with the knee against the back if necessary — drawing the shoulder forcibly backward and upward. Retention is more difficult. The splint should draw the shoulder upward, outward, and backward; to this end' there are about seventy splints (Gurlt) of varying utility. Many of these, useful and celebrated in their time, have been modified Fig. 6. Fracture of the left clavicle. Modified Sayre dressing. Towel circular of upper arm held by adhesive plaster. Adhesive-plaster strap ready. (Scudder on Fractures.) and replaced by others, so that mention only is necessary. Petit's figure-of-eight bandage across the back, drawing the shoulders firmly backward, accomplishes by force what Hippocrates' method effected by gravity in the dorsal position with a pad between the shoulder- blades. Desault's and Velpeau's (Fig. 5) dressings are historical. To immobilize the upper extremity in many conditions — as in dislocations — they are both effective. But' in their original purpose, fixation of the clavicular fragments, they fail entirely. In emergency the towei bandage of Szymanowski is useful. A three- cornered cloth is laid upon the sound shoulder; a second piece, fastened about the upper part of the upper a-m of the affected side, draws it backward; a third piece around the lower part of the upper arm FRACTURES OF THE CLA VICLE. 31 draws it backward and upward, and a fourth about the elbow supports it and the forearm over the chest. Sayre's splint should be classed among the most practical. Even this has the disadvantage of occasionally producing eczema, ecehy- mosis, and abrasions, particularly in obese individuals or those with delicate skin, and of leading to infection. Individuals who perspire freely have sensitive skin; the plaster also slips easily. To obviate these conditions, elastic bands are recommended, as, for example, Fig. 7. Fig. S. Fracture of the left clavicle. First ad- hesive-plaster strap applied. Shoulder carried backward. Fixed point established above middle of humerus. (Scudder on Fractures. ) Fracture of the left clavicle. First adhesive- plaster strap applied. Second adhesive-plaster strap being applied. Hole in plaster for olecranon visible. Note pad for wrist and folded towel protecting skin of arm and chest. (Scudder on Fractures.) Biingner's three-ply elastic splint. Of complicated apparatus, the one described by Heusner (1895) seems most practical. (Fig. 12.) From extensive personal experience Schreiber recommends the epaulette splint of Braatz (Fig. 13), which follows the principle of the Sayre splint, but purposes to avoid its objections. The elbow of the injured side is covered in semiflexion with a well-padded plaster sheath. A similar covering is placed on the sound shoulder — not wide enough to hinder abduction. After they have hardened, the arm is lifted by an arm strip like the II strip of the Sayre splint (Figs. 7 to 11), and another strip like the I of the Sayre is fastened to the upper third of the arm and passed across the back and fastened in front. A third strip replaces the III of the 32 MALFORMATIONS AND INJURIES OF THE SHOULDER. Sayre. The whole is reinforced by a few turns of a bandage. Pro- jections may be moulded in plaster upon the shoulder-cap to prevent the bandages from slipping sideways. The best results are obtained by Bardenheuer's method of forcible traction, valuable for marked displacement, and particularly indicated when the patient is recumbent by reason of other injuries. A broad strip of adhesive plaster with about six to eight pounds attached draws the shoulder and upper end of the humerus upward and back- ward. The forearm is fixed in the Velpeau position with adhesive Fig. 9. Fig. 10. Fracture of the left clavicle. First and second adhesive-plaster straps ap- plied. Pad in left hand. Shoulder pulled backward and elevated. (Scudder on Fractures. ) Fracture of the right clavicle. Modified Sayre dressing. Posterior view. Shoulder elevated and pulled backward. Folded towel seen in axilla for protection to skin. (Scud- der on Fractures. ) plaster and the lower end of the humerus pulled downward by counter- extension toward the other side of the bed. A firm pad is laid between the shoulders so that they sink backward. The pad alone, as used by Hippocrates, suffices for cases with slight displacement. Suture of the bones is indicated only for rebellious fragments and for compound fractures. Dawson, Langenbuch, Bardenheuer, Demons, and Lejars have obtained good results by suturing; Fevrier has col- lected 44 cases. Other authors insist that even after suturing the result is not certain, and that inc'sion adds to the dangers of the Fli.\("iri;i:s of THE CLA VWLE. 33 Fracture of the clavicle and subluxation of the acromioclavicular joint. Notice elevation of sin miller by pressure on the flexed elbow and counterpressure on the clavicle by a bandage and a pad (X) placed internal to the acromioclavicular joint. (Scudder on Fractures.) I Fig. 12. Heusner's apparatus for fracture of the clavicle Vol. III.— 3 34 MALFORMATIONS AND INJURIES OF THE SHOULDER. injury. In the subjects — young women — in whom we desire the least deformity the scar on the shoulder is most objectionable. Lejars rec- ommends binding two pieces of stiff wire to the fragments. Operative procedures may be necessary secondarily if a projecting fragment threatens to perforate the skin or if a hypertrophied callus by pressure upon the brachial plexus causes neuralgias or paralyses, or if a pseudo- arthrosis compromises the function essentially. Fig. 13. Braatz epaulette dressing for fracture of the clavicle. Gunshot-fractures of the clavicle derive special significance from asso- ciated injuries of the nerves, vessels, ribs, pleura, or lung. The latter are decisive for the mode of treatment. Where absent, the treatment differs from that of a subcutaneous fracture only in the application of an aseptic dressing. Complications may ensue even at a remote period after the injury. Fischer saw 2 cases of empyema requiring incision following gunshot-fracture of the clavicle. DISLOCATIONS OF THE CLAVICLE. The strong coracoclavicular and costoclavicular ligaments uniting the clavicle to the first rib and to the scapula readily explain the infre- quency of dislocation — according to Gurlt, 4.S8 per cent. The brittle clavicle is more easily fractured than dislocated. Malgaigne, Fischer, DISLOCATIONS OF THE CLAVICLE. 35 and others regard dislocation of the acromial end as more frequent, which corresponds with Schreiber's experience, in that he has seldom observed the sternal luxation — less frequently than is stated by Pitha. Fig. 14. Coracoid process. Coraeo-acromial ligament Long tendon of biceps. Glenoid cavity. Outer end of clavicle. Deltoid. Infraspinatus. Old supra-acromial dislocation of clavicle. Dislocation of the Acromial End of the Clavicle. Dislocation of the acromial end of the clavicle may occur upward or downward, and may be complete or incomplete. Dislocation Upward. — Dislocation upward (luxatio supra-acromialis clavicularis or luxatio scapula? infraclavicularis) occurs, according to Gurlt and Kronlein, with a frequency of 2.4 to 2.7 per cent.; Defran- ceschi places the frequency at 6 per cent. It is more common in males of advanced age, and is oftener complete than incomplete. Etiology. — The cause is almost always direct violence applied to the acromion from above downward. The clavicle is pushed downward, strikes against the first rib, is pushed forward, and with the tearing of the acromioclavicular ligament the outer end glides upward over the acromion. This action may be produced by a blow, by a heavy body falling from above, by a fall upon the shoulder, by being run over. (Boudaille.) The acromion is drawn downward by the weight of the extremity, according to the extent to which the ligaments are torn. Consequently rupture of the acromioclavicular ligament alone permits only of incomplete luxation, while complete luxation presup- poses rupture also of the coracoclavicular ligament. Symptoms. — The pathognomonic symptom is the step-like projection of the end of the clavicle (Fig. 15), which may be f, f, or even 1 to It inches above the acromion, according to the extent to which the ligaments are torn. The projection moves with the clavicle and can be pushed backward and forward. In complete dislocation, as the 36 MALFORMATIONS AND INJURIES OF THE SHOULDER. clavicle no longer acts as a support, the shoulder sinks forward, down- ward, and inward. Abduction is prevented by the pain. Diagnosis. — The diagnosis of complete dislocation is easy from the symptoms as described. Against fracture of the clavicle are the equal length of the two clavicles, the absence of crepitus, and the palpation of the deformity, easily effected by elevating the arm. Confusion with dislocation of the shoulder is almost out of question if the exami- nation is careful. An .r-ray examination may deceive in two ways: the normal space between the acromion and clavicle — in avray pictures Fig. 15. Complete supra-acromial dislocation of the clavicle. (Stimson.) often almost a finger's breadth — may be mistaken as representing dias- tasis, or in exposures in the dorsal position the shoulder may sink so far backward that in spite of the existence of dislocation a normal picture is obtained. Prognosis. — As regards complete restoration of form, the prognosis is not favorable, but functional impairment is slight even in complete dislocation with marked deformity. In general, however, the functional disturbance is severe in proportion to the deformity. The carrying of heavy burdens is particularly difficult, so that carpenters, porters, masons, etc., are hindered in their vocations. Abduction above a DISLOCATIONS OF THE OLA VICLE. 37 horizontal may be prevented permanently. Schreiber has seen a deforming arthritis develop after dislocation. Treatment. — Reduction is by retraction and elevation of the shoulder combined with direct pressure upon the acromial end. Retention is difficult, and the numerous clavicular splints are about as unsatisfactory as Nielaton's complicated apparatus with pads and Laugier's apparatus with tourniquets. Adhesive plaster makes the best splint. While reduc- tion is maintained by downward pressure upon the shoulder and upward pressure upon the elbow a strip of adhesive plaster is applied over the end of the clavicle, carried firmly down the posterior surface of the arm, around under the padded elbow, up the inner surface of the arm, and with tension over the shoulder again to the back. A few turns of bandage are made around the upper arm to fix the plaster strip, and the forearm, bent sharply, is hung in a sling. To obviate the danger of decubitus, Hofmeister places a plaster-of- Paris pad about 6 inches long upon the shoulder, over which the adhe- sive strips cross. The results are good. In place of the adhesive strips Leidy Rhoads recommends a leather strap and buckle to lift the shoulder; it may be tightened as desired. Bardenheuer draws the arm and clavicle downward by means of an adhesive plaster traction splint with the patient in the dorsal position. Another strip passes over a pad in the axilla and draws the scapula upward, the two ends crossing over the clavicle. For ambulant treat- ment he recommends his spring-extension splint — without the shoulder- brace and cap — shifting it forward or backward according to the direction of the dislocation. As the methods mentioned not infrequently fail, fixation by suture has been tried. Baum draws the torn ligaments together with two subcutaneous silk ligatures, reduces the dislocation, and ties the ends of the sutures over a roll of adhesive plaster, analogous to Volkmann's patellar ligature. The arm is supported in a sling. Helferich and others commend this method. The subcutaneous suture is now super- seded by the open method with wire sutures. Its use in recent cases is advocated by many. Krecke and others emphasize the importance of not depending too much upon the probability of a favorable outcome, but rather of trying to remove completely the deformity and restore the normal function. Suture accomplishes this without danger, and should be applied particularly in the case of laborers, who require the full function of the shoulder. It has been used by Paci, Poirier, J. Wolff, and others. Krecke obtained primary union in 2 cases. He does not use drainage, as it is too apt to be followed by a sinus, which may necessitate removal of the sutures. In such sutured cases active motion is permitted in two weeks, thus avoiding any great muscular atrophy. Dislocation Downward. — Subacromial dislocation (luxatio subacromi- alis) is a rare injury. Less than 12 cases are recorded. It is caused generally by a blow upon the upper surface of the clavicle while the arm is abducted, the force driving the clavicle downward. It may 38 MALFORMATIONS AND INJURIES OF THE SHOULDER. result from a fall upon the elbow with the shoulder fixed or encumbered, the force driving the acromion upward. Symptoms. — The symptoms are usually distinct. The shoulder is somewhat depressed; pain is felt at the affeeted spot and is increased by active and passive motion. The hollows above and below the clavicle are effaced; the clavicle recedes rather abruptly from its middle point toward the shoulder; the sternal end frequently projects. The acromial end is absent at its normal position; the acromion projects sharply, so that the joint surfaces may be felt in fresh cases. The acromion appears to be nearer the middle line. Formication from pressure upon the plexus is rare. Functional disturbance is marked. Abduction especially is impaired. Diagnosis. — The diagnosis, on account of the concealed position of the dislocated end, is not simple. The depression of the outer part of the clavicle is significant. It is noticeable even with much swelling if the clavicle is palpated from its inner end, the finger coming abruptly against the facet of the projecting acromion. The head of the humerus is easily recognized in its normal position. Prognosis. — The prognosis of subacromial dislocation is not un- favorable, even if non-reduced. Usually no important functional disturbance follows and a serviceable nearthrosis forms, muscles and bones adapting themselves to the new position. Treatment. — Reduction is by backward traction on the shoulder — or indirectly by pulling outward and backward on the abducted arm — and by simultaneous upward pressure upon the clavicle. Retention is by means of an axillary pad and fixation of the hand upon the other shoulder. Subcoracoid dislocation is reduced in the same manner, but may require more force and some assistance to disengage the end of the clavicle from beneath the coracoid process. Subcoracoid Dislocation. — Godemer and Pinjou describe a more marked form of downward dislocation (luxatio subcoracoidea) in which the outer end of the clavicle is supposed to be dislocated under the coracoid process. Naturally it is only possible after rupture of all the ligaments — acromioclavicular and coracoclavicular. About 6 cases are reported. The authenticity of some cases is doubted (Hamilton). Terrier and Ginestone observed this form combined with dislocation of the shoulder. The symptoms are striking prominence of the acromion and coracoid process and a deep depression at the outer end of the clavicle. The end of the bone may rest against the head of the humerus or be felt in the axilla. Dislocations of the Sternal End of the Clavicle. The sternoclavicular joint is divided by a meniscus into two parts. Dislocation may occur proximal or distal to the ligamentous disk. Dislocation of the sternal end is possible in three directions: (a) Forward, luxatio prsesternalis. (6) Upward, luxatio suprasternal. (c) Backward, luxatio retrosternalis. DISLOCATIONS OF THE CLAVICLE. 39 Dislocation Forward. Of the three forms, this is the most frequenl and represents about 1.5 per cent, of all dislocations. It occurs chiefly during middle age and in men, and is more frequently complete than incomplete. Etiology. — The cause is excessive backward motion of the shoulder from a blow, a fall, run-over accident, machinery accident, etc.; also the sudden slipping from the shoulder of a strap used in carrying burdens. Less often it results from muscular traction as in hurling heavy objects, gymnastic and military exercises, etc. It is seen occasionally as a complication of fracture of the acromion, of the coracoid process, or of the upper ribs. Stetter believes the presternal position is secondary to the suprasternal dislocation, and is the result of a force exerted from in front striking the depressed shoulder and driving the sternal end against and through the upper capsule, and that it is more frequent than the fulcrum action of the first rib, described by Hiiter, when the acromion is pressed forcibly downward. Symptoms. — The symptoms are continuous pain in the joint, inclina- tion of the head toward the affected side, and depressed shoulder. The dislocated head projects forward, especially in recent and old cases, a projection made more distinct by motion. The line of the clavicle is less prominent. At the joint a depression is palpable. The distance from the sternum to the acromial end and to the midpoint of the incisura jugularis are shortened. Sometimes pressure upon the nerves causes numbness and tingling in the arm. Often the function of the arm is impaired so slightly that the patient considers medical aid unnecessary. Diagnosis. — The diagnosis is rendered difficult only by a thick panniculus or extravasation and by complications. In fractures near the joint crepitus is usually obtainable. Prognosis. — The prognosis is generally favorable. Even with incom- plete reduction full use of the arm returns. In certain cases, however, the functional disturbances may be more severe. The deformity is rarely reduced completely — that is, an incomplete dislocation persists. Treatment. — Reduction is by backward and outward traction upon the shoulder and pressure upon the sternal end of the clavicle. Reten- tion is rarely successful regardless of the splint or apparatus used. Konig recommends rubber plates fastened down by adhesive strips. Barden- heuer advocates forcible traction, as for fractured clavicle, combined with the pressure of a pad; or Malgaigne's hook; or his spring-traction splint. [Stimson advises a figure-of-eight adhesive- plaster splint crossing in front with pad or moulded plaster, and for severe cases the dorsal position with appropriate pressure — even digital if necessary. He has obtained good results from the periarticular injection of alcohol. The various operative procedures recommended by Konig (suture of the capsule), Gersuny (transplantation of the sternocleidomastoid), and others are not widely employed in America.] Dislocation Upward. — Luxatio suprasternal is much less frequent. About 20 cases are recorded. In this accident the end of the bone is 40 MALFORMATIONS AND INJURIES OF THE SHOULDER. forced through the upper part of the capsule, the costoclavicular and sternoclavicular ligaments are ruptured, and the head passes further between the sternomastoid and sternohyoid muscles even into the neck, and has been pushed even up to the larynx. The cause is forcible depression of the shoulder downward and backward; or leverage upon the first rib from direct violence upon the depressed shoulder; also a fall, etc. A. X. Blodgett reports the case of a man carrying one end of a piano, in which the sudden dropping of the other end pro- duced an upward and inward dislocation of the clavicle and a forward and outward dislocation of the first and second costal cartilages. Symptoms and Diagnosis. — The symptoms are protrusion of the end of the bone in the neck, flattening of the shoulder downward and inward, obliquity of the clavicle, shallowness of the infraclavicular and supra- clavicular depressions; less frequently severe pain and aphasia or dyspnoea from pressure upon the larynx. Treatment. — Reduction is by outward traction upon the shoulder and direct pressure downward upon the end of the bone. Retention is seldom complete. Bardenheuer recommended continuous traction upon the arm. Dorsal position and fixation of the shoulder have given fairly good results. Andrews advises a figure-of-eight bandage with a pressure-pad and fixation of the head inclined slightly forward and rotated to relax the sternomastoid. [The operative procedures of sutur- ing and fixing with bone pins have few advocates in America.] Dislocation Backward.— Luxatio retrosternalis is rare [second in frequencv, Stimson]. Malgaigne collected 11 cases [Stimson gives only 2 cases as coming under direct examination]. The dislocation may be complete or incomplete. In the former the degree of displacement differs greatly, a fact which has led to subdivision by many authors. Etiology. — The cause is direct violence from the front pushing the end of the bone through the capsule, or indirect violence, by which, the shoulder being pushed forward from behind, the force is transmitted through the rigid clavicle in the opposite direction, that is, backward. In complete dislocation the capsule is torn entirely, the interarticular cartilage remaining attached to the sternum. The head of the clavicle is dislocated backward and may press upon the carotid or jugular, the subclavian artery and vein, or upon the phrenic nerve or vagus. In the same way the oesophagus or trachea may be compressed. Schreiber saw a case in which the trachea was ruptured. Symptoms and Diagnosis. — The most striking symptom is the absence of the head of the clavicle at its normal position, in place of which a distinct pit is palpable. The head is felt more or less deeply in the neck behind the sternum as a hard rounded body which moves with the shoulder. The supraclavicular and infraclavicular depressions are shallower. The sternomastoid is more prominent on the unaffected side. The shoulder projects forward somewhat. The head pressing upon the structures behind may produce circulatory disturbances in the arm — absence of radial pulse; and in the head — syncope, tinnitus. There may be dysphagia, singultus, and dyspnoea even to absolute FRACTURES OF THE SCAPULA. 41 asphyxia. In Schreiber's ease a cutaneous emphysema developed rapidly, and completely concealed the deformity. Except for the rare complication of emphysema or marked traumatic swelling about the joint the diagnosis is simple. Prognosis. — The prognosis is not unfavorable, as usually the func- tion of the pails is regained even if retention is incomplete. Compli- cations may be serious — for example, a case of rupture of the trachea was fatal from empyema. Usually the tissues adapt themselves to the pressure, so that the troublesome symptoms disappear spontaneously. Treatment. — Reduction is by strong traction backward and outward Upon both shoulders, with the knee between the shoulder-blades if necessary; the impulse forces the head of the bone forward. In the presence of threatening symptoms one might draw the head forward with a blunt hook (a questionable procedure). The method of retention is the same as for forward dislocation. The shoulder should be held back firmly and the dressing examined frequently to prevent recurrence. Total Dislocation of the Clavicle. Dislocation of the clavicle at both ends is very rare. Lucas collected 10 cases, all occurring between the ages of thirteen and thirty-nine. In younger subjects fracture is more apt to occur. Of Kaufmann's 8 cases, 7 were in males, of which 6 were adults. They resulted from force from behind pressing the shoulders together in such a way that wdiile one shoulder was fixed the body was rotated about it; as in run-over accidents, car-buffer accidents, fall from a height, from driver's seat, etc. Parral regards unusual solidity of the clavicle as the common predis- posing cause. Symptoms. — The symptoms are those of sternal and acromial dis- location combined. The entire clavicle is abnormally movable and yields to upward and downward pressure. It may be rotated easily on its mid-axis. Prognosis. — The prognosis is not unfavorable. In none of the cases was there any permanent loss, and as a rule the functional result was good. Treatment. — Reduction is usually easy by backward traction upon the shoulder combined with pressure upon the sternal end of the clavicle. Retention is difficult. In Kaufmann's case presternal dislocation persisted. Pathological dislocations have been seen associated with spinal curva- tures, bone and joint diseases. Cooper was compelled to resect the head in a case of posterior dislocation following scoliosis. FRACTURES OF THE SCAPULA. Fractures of the scapula are comparatively rare — about 1 per cent, of all fractures. Bruns gives 0.86 per cent., Richter 4 per cent. They 42 MALFORMATIONS AND INJURIES OF THE SHOULDER. occur most frequently in males between the ages of twenty-one and fifty years, rarely in women, even more so in children. We dis- tinguish: 1. Fractures of the body and of the angle of the scapula. 2. Fractures of the glenoid cavity. 3. Fractures of the neck. 4. Frac- tures of the acromion and of the spine. 5. Fractures of the coracoid process. In order of frequency Ricard gives fractures of the body, of the neck, of the acromion. Fracture of the Body of the Scapula. — Fractures of the body occur as fissures, without essential displacement; as complete fractures, either longitudinal, transverse, stellate, or comminuted. Transverse fractures are most commonly situated below the spine in the infraspinate fossa, and are sometimes double. They result from direct violence, as from street accidents, blows upon the shoulder, or the impact of heavy bodies, as in quarries from blasting, and are therefore accom- panied by severe contusion of the soft parts, which often leads to the formation of a fluctuating hematoma. Compound fractures are rare on account of the thick padding formed by the soft parts. Single frag- ments when free are usually displaced by the traction of attached muscles — for example, in a transverse fracture of the lower scapular angle the lower fragment will be drawn upward, forward, and out- ward by the serratus magnus and teres major. In fractures of the upper angle the latter will be drawn upward and inward by the levator angulse scapulae. Symptoms and Diagnosis. — The important symptoms are localized pain, abnormal mobility of the parts, changes in the contour of the scapula, and crepitus. They may be marked or slight. Especially the incomplete and longitudinal fractures may escape diagnosis. The dis- placement is most easily detected, according to HofYa, by drawing the arm behind the back, thus bringing out the wing shape of the scapula. Prognosis. — The prognosis of fractures of the body of the scapula, disregarding complications, is favorable, as recovery is good even if the fragments cannot be accurately apposed. The occasional irregu- larity in form affects the function of the scapula but little. Exostoses or inflammatory processes in the bursa subserrata may produce perma- nent disability — e. g., for porters, etc. Treatment.— The treatment consists in fixing the arm upon the chest in the position most effectually approximating the fragments. The Velpeau position is usually the best. Gurlt recommends a shield of long adhesive strips; Konig, suture of the bone. [Operative interference is not advisable as a rule for simple fractures. For compound fractures of the body, Stimson emphasizes the necessity, in addition to the usual procedure for open wounds, of removing any fragments of bone which are liable to prevent free drainage and lead to burrowing of pus upon the costal surface of the bone, a possibility peculiar to the region. He notes that simple cases have become purulent, apparently from im- perfect immobilization, the pus burrowing downward.] Fracture of the Angles.— Isolated fractures of the upper and lower angle of the scapula have been seen, usually from direct violence— ?. g. y FRACTURES OF THE SCAPULA. 43 from a blow, a push, falling backward upon stairs, etc. They occur rarely from muscular traction. Guinard saw such in a hoy who tried to free himself from beneath his opponent in wrestling. The separation of the lower angle is usually more or less transverse, often with fissures in the body of the scapula. Displacement i> generally marked. In a case of Sabatier's the fragment was so sharp that it threatened to per- forate the skin. Fracture of the Glenoid Portion.— Fracture of the articular portion of the scapula not only occurs as a "chipping off" of parts of the rim in connection with dislocation of the shoulder (Fig. 16), hut especially as an avulsion of the entire articular portion — fractura colli anatomica. Gurlt, Spencer, and Volkmann have seen this rare injury. It is usu- ally the result of a fall upon the shoulder, and of hyperahduction if the ligaments are less yielding than the bone. Fig. 16. Fig. 17. Fig. 16. — Incomplete longitudinal fracture of the glenoid cavity, (v. Bruns.) Fin. 17. — Fracture •partial i of the neck of the scapula, b. Upper line of the glenoid cavity. d. Intact portion of the glenoid cavity, e. Lower fragment, (v. Bruns.) The symptoms will be found given under the description of the fractura colli chirurgici, from which the symptoms of fracture of the anatomical neck differ only in that the coracoid process is in its normal position and does not follow the movements of the arm. Chipping of the glenoid margin is recognizable with certainty only when, secondary to the symptoms of joint contusion, bony crepitus is obtainable or the .r-ray shows the condition. Fracture of the Surgical Neck. — Of greater practical importance is fracture of the surgical neck, in which the articular portion breaks off simultaneously with the coracoid process, so that the line of fracture, according to Lotzbeck, runs downward from the incisura scapula?. Among 1901 fractures seen by Lonsdale in the Middlesex Hospital there were 18 of the scapula and 2 of the neck; Lente saw 17 of the scapula and 1 of the neck in 1722 cases; Weber 3 of the neck among 16 of the scapula; Lotzbeck 2 among 12. The cause is usually direct violence — a blow, a push, street accidents, fall from a wagon, fall upon the stairs, fall from a horse, rarely by muscular action — e.g., in throwing a scarf over the head as cited by G. May. 44: MALFORMATIONS AND INJURIES OF THE SHOULDER. Symptoms and Diagnosis. — The symptoms are flattening of the shoulder, prominence of the acromion, as a rule lengthening of the arm — 1 to 2 inches. Often the head of the humerus cannot be felt in the axilla, but instead one feels the sharp, irregular edge of the fracture, manipulation of which is painful. The arm is abducted and is not in the axis of the shoulder-joint, so that it resembles a dislocation. The lowered position of the coracoid process is recognizable at times. Usually it is readily seen that it follows the movements of the arm. The diagnosis is essentially a differential one from dislocation of the humerus. The free mobility and easy reducibility of the deformity are conclusive. On elevating the arm and making pressure in the axilla the deformity disappears, to return as soon as the arm is released. Distinct crepitus is felt at the same time as well as in rotating the arm, if the middle finger is placed upon the site of the coracoid, the thumb upon the posterior surface of the arm. Prognosis. — The prognosis is favorable even if some displacement remains. Commonly abduction is somewhat impaired. The period required for union is usually from ten to twelve weeks. A few cases have recovered with pseudarthrosis. Treatment. — Reduction is by upward pressure upon the humerus; re- tention is effected by means of an axillary pad, with an appropriate bandage supporting the elbow (Desault's dressing — Lotzbeck); plaster splint (Konig); Middeldorpf's triangle. Sayre's adhesive-plaster dress- ing is largely used at the present time. Bardenheuer recommends his spring-extension splint or the recumbent position and upward and outward traction on the adducted arm. From personal experience the author can recommend suspension of the arm with the patient in the lateral position. [Stimson recommends his splint used for dislocation of the acromial end of the clavicle, carrying the strips further inward on the shoulder, but questions the ability of any dressing to retain the fragments exactly.] Fracture of the Acromion and Spine. — Fractures of the acromion and spine are not infrequent on account of their exposed position. In IS fractures of the scapula Lonsdale gives 8 of the acromion. The cause is usually direct violence, as by striking the top of the shoulder in falling; rarely indirect, as in falling upon the arm or by strong con- traction of the deltoid (Michou). The line of separation is usually transverse; by direct force it is nearer the joint, by indirect force nearer the base. In youth these fractures are replaced by separation of the epiphysis. The periosteum often remains intact, especially on the under surface. Symptoms and Diagnosis. — Fracture of the acromion is characterized by local pain increased by pressure or elevation of the arm. In the absence of displacement there is no deformity. With marked projection of the fragment the condition may resemble upward dislocation of the clavicle. Occasionally the cleft can be felt, especially on pulling the arm down- ward. Crepitus is obtained by lifting the arm. FRACTURES OB THE SCAPULA. 45 Prognosis. — Union requires from four to five weeks. The prognosis is usually favorable. Rarely, pseudoarthrosis occurs, bul it' firm produces no functional disturbance. Treatment. — The treatment is similar to that of supra-acromial dis- location of the clavicle. Fractures of the Coracoid Process. Fracture of thecoracoid pro< ess is one of the rarest of bone fractures, and is usually accompanied by other injuries of the scapula and clavicle, or complicates dislocation of I la- humerus. The base of the process is the common seat of fracture. Any great displacement presupposes rupture of the coraco- acromial and coracoclavicular ligaments. Etiology. — The cause is usually direct violence — blow from a wagon- pole, kick of a horse — but there are instances in which the fracture was produced by indirect violence, especially muscular traction (wringing out wash, throwing, forced supination — Holmes, Gurltj. Bennett records a case of epiphyseal fracture of the coracoid from tetanic con- vulsions in a child of six years. Symptoms. — The symptoms, in the absence of dislocation, are chiefly local pain, extravasation of blood in the region of the coracoid, abnormal mobility, and crepitus. Pain is felt chiefly on deep inspiration and in elevating the arm, as the pectoralis minor thereby pulls upon the process; also in flexion of the supinated forearm from traction of the short head of the biceps; with the forearm pronated, pain is absent, as the biceps is then inactive. Any considerable displacement of the process is dependent upon laceration of the ligaments. Then the pectoralis minor, biceps, and coracobrachialis draw it downward and inward. Usually, however, as mentioned, other severe injuries are present so that the symptoms of fracture of the coracoid process are obscured. Treatment. — Fixation of the arm in acute flexion with a sling or Yelpeau bandage. [Theoretically the best position of the arm to relax the muscular traction on the process would be in acute flexion across the chest, the hand resting on the other shoulder. The consequent discomfort, however, may compel modification.] Gunshot-fractures of the Scapula. — Gunshot-fractures of the scapula are relatively frequent. The lesion may be a mere perforation or a comminuted fracture with many fissures. The adjacent structures — clavicle, shoulder-joint, ribs, lungs, etc. — may be involved, especially by shots directly forward or backward. Among the numerous scapular wounds in the South African War Kiittner saw only one case of splinter- ing; sensitiveness to pressure, however, was always extensive and indic- ative of fissures. The injury may occur by way of the axilla, as ob- served once by Stromeyer. If infection takes place, the fascial arrange- ment about the overlapping muscles is peculiarly favorable to the development of extensive gravitation abscesses. 46 MALFORMATIONS AND INJURIES OF THE SHOULDER. CONTUSIONS AND SPRAINS OF THE SHOULDER-JOINT. Contusions and sprains of the shoulder-joint are frequent injuries which demand the careful attention of the surgeon, as they often give rise to persistent functional disturbances that are out of all proportion to the presumably slight primary injury. Among the cases regarded as sprains are unquestionably some in which small fragments of bone have been chipped from the glenoid margin or in which the capsule is torn. Even contusions are very apt to be followed by stiffness and especially by impairment of abduction. The pain causes the patient to hold the arm guardedly against the chest, and frequently the sur- geon, uncertain as to the treatment required or misguided by a wrong diagnosis, immobilizes the arm in this position for some length of time. A few weeks of such treatment, aided by the traumatic infiltration of the tissues, suffice to constrict the capsular pouches, which facilitate the free movements of the shoulder, to such an extent that combined with the adhesions forming in the subdeltoid bursa and the shortening of the adductors, free elevation of the arm is irrevocably lost. In Germany modern accident legislation has not only brought the atten- tion of the profession to the unhappy results of slight shoulder-injuries, but in addition has been directly influential in increasing the percent- age of bad results, in that it has caused the patients to do, consciously or unconsciously, the very things that hinder recovery. Thiem, in his text-book of accident surgery, has ably characterized the disastrous influence of modern legislation upon the prognosis of shoulder injuries. The secret of success in the prophylaxis of joint stiffness lies in insti- tuting motion from the first day. The measures will be discussed later under contractures of the shoulder-joint. According to Dittmer, of 28 cases of sprain of the shoulder, only 5 were cured by an average treatment of 9.4 months; after thirteen months in 23 cases there was still an average disability of 21.4 per cent. WOUNDS OF THE SHOULDER-JOINT. Wounds of the shoulder-joint are produced by sharp and pointed instruments and firearms. Although puncture wounds are not in- frequent, very few cases are recorded in which the joint has been opened from above by incised wounds cleaving the shoulder or separating the head of the humerus from its shaft. From the site of the injury one can make a probable diagnosis and assume an injury of the joint if a vertical puncture wound is situated at the outer side of the coracoid process. A puncture wound extending downward and outward from the inner side of the coracoid process will probably involve the glenoid margin or the head of the humerus. Naturally the position of the arm at the moment of injury is important. For example, if the arm is elevated the contracted and thickened deltoid may be perforated without Wnl'.XPS <>F TUK KIWULDEH JOIST. 47 the foinl being involved; when the arm hangs down, the capsule is thrown into folds in the axilla, so that a horizontal puncture or shot- wound may injure the capsule and not the hour. Discharge of synovial fluid has been demonstrated in very few cases. The post-traumatic inflammation is usually the first sign of joint involve- ment, so that cases that progress favorably from the outset are often not recognized as joint injuries. Gunshot-wounds. — Gunshot-wounds are the most important and almost the only injuries in war involving the shoulder-joint. They are not infrequent, about 1.3 to 3.4 per cent, of all gunshot-wounds, 10.5 to 1.").'.) per cent, of the shot-wounds of the joints. The left shoulder is injured more often than the right, as the latter is protected by the gunstock while firing. The ball usually enters Fig. 18. Fig. 19. Fig. 20. Resection specimens from Franco-Prussian War. (v. Bruns.) FlG. 18. — Ounshot-fraeture of the head of the femur, with extensive splintering. Fi<;. 19. — Gunshot-wound of the epiphyseal line, witli Assuring of the head. FlG. 20.— Gunshot -fracture of the shaft (butterfly fracture), with separation of the epiphysis and Assuring of the head. downward to the outer side of the coracoid process and emerges behind near the teres minor. The arch of the shoulder may be broken with or without injury of the capsule, or the capsule alone may be affected. We distinguish: wounds of the capsule; furrow T wounds, in which the articular head or the glenoid cavity show only a groove; pene- trating wounds with or without fissures. (Fig. 19.) The old leaden bullets usually produced comminuted fractures, the bone being more or less splintered, especially by close-range shots. (Fig. IS.) The modern metal-coated bullet as a rule produces a penetrating or furrowed wound in the head of the humerus. (Kiittner.) The involvement of the joint is surprisingly slight. Further, we distinguish perforating w T ounds, the most common form produced by the modern bullets, and 48 MALFORMATIONS AND INJURIES OF THE SHOULDER. those with enlodgement of the bullet. Gunshot-wounds of the joint are produced indirectly by fissures radiating to the joint from a gunshot fracture of the humerus or scapula. (Fig. 20.) In young subjects the cartilaginous epiphyseal disk may interrupt a fissure emanating from the diaphysis. The dislocations and subluxations seen in rare cases result- ing from lead-bullet injuries do not apply to metal-coated bullets. Prognosis. — The prognosis of shot-wounds of the shoulder-joint depends upon two factors: the nature of the injury, depending in turn upon the weapon; and, more important, the primary treatment. Com- plications — that is, injuries of the adjacent structures — may exercise naturally a priori an incalculable influence. The mortality statistics of earlier wars are to-day valueless. Treatment. — The primary aseptic occlusion as proposed by v. Berg- mann applies to the shoulder-joint as well as to other parts. Kiittner emphasizes the value of immobilization. If recovery is uninterrupted, it is continued for four weeks, to be replaced later by medico-mechanical treatment. He obtained good functional results. The favorable results of conservative treatment were recorded as early as the Franco-Prussian War by Ernesti — c. g., 36 per cent, of partially, 10 per cent, of freely movable shoulder-joint, and a mortality of 10 per cent. It is well known that a lodged bullet is not an indication per se for primary interference. Primary resection, so prominent in the treatment of wounds in earlier wars, is to-day the exception. In cases of severe comminution and extensive injury of the soft parts it is advisable to remove all splinters, shreds of tissue, foreign substances, restore the parts to their normal relation as far as possible, and to pack the wound lightly, and to drain thoroughly. All necessary incisions should avoid functionally important structures if possible. Careful ligation and the least possible manipu- lation of the wound are regarded now as important details in the treat- ment. The treatment of an intercurrent infection and of cases already infected will be considered later under Purulent Inflammation of the Shoulder-joint. Amputation at the shoulder is indicated only in cases with severe injury of the extremity, of the large vessels and nerves, or occasionally in injuries from large projectiles. The great frequency of this operation in earlier wars — Pirogoff cites 30 cases after the first bombardment of Sebastopol — is reduced at the present time by the better prognosis of conservative treatment and resection. It was seldom performed in recent wars. In 31 cases of artillery- wounds and 6S of rifle- wounds of the upper extremity Kiittner and Matthiolius were obliged to do only one amputation, and that in the case of a man, seen for the first time on the sixteenth day, with suppuration of the wrist-joint and well- developed sepsis. All other injuries of the large joints of the arm (7) recovered without operation. FRACTURES OF UPPER END OF UPPER EXTREMITY. 49 FRACTURES OF THE UPPER END OF THE UPPER EXTREMITY. Fractures of the humerus in general have a frequency of 7 per cent. The upper and lower ends arc involved about equally often; the diaphysis twice as often, according to Bruns. In 61 cases Poirier saw the upper part involved 41 times, the lower 12 times, the middle 15 times. Fracture of the upper end of the humerus occurs most frequently in advanced age, when the resistance of the bone is diminished, and in youth from the lesser resistance of the epiphyseal line. Men are oftener affected than women — 35 to 2, according to Decamp. Fig. 22. Fig. 23. Pig. 21.— 1. Fracture of the anatomical neck. 2. Fracture through the tuberosities (pertuber- cularis). 3. Fracture of the surgical neck. Fig. 22.— Fracture of the anatomical neck and through the tuberosities (Y-fracture with dis- placement and abduction). Fig. 23.— Fracture below the tuberosities (subtubercularis), with abduction and impaction (front view). Kocher distinguishes the following forms, according to the anatomical position : Supratubercular (intracapsular) fractures: 1. Fracture of the head. 2. Fracture of the anatomical neck. (Fig. 21, 1.) Inf ratubercular fractures : 1. Fractura pertubercularis, including fracture of the epiphyseal line. (Fig. 21, 2.) 2. Fractura subtubercularis, corresponding to fracture of the sur- gical neck. (Fig. 21, 3.) 3. Y-fracture, by combination of two lines of fracture. 4. Isolated fracture of the greater or lesser tuberosity. The fracture line is usually transverse, less often oblique or markedly zigzag. According to the cause, we distinguish compression, abduc- tion, adduction, flexion, extension, and torsion fractures. Compres- sion fractures may be supratubercular or infratubercular. Fracture by bowing is always infratubercular, as during a blow or movement Vol. III.— 4 50 MALFORMATIONS AND INJURIES OF THE SHOULDER. only that part of the head is fixed which lies within the capsule and tendinous attachments. The pure supra tubercular forms are rare; the combined forms, partly supratubercular, partly infratubercular, are frequent, the subtubercular more so. The combined forms are easily produced by pressure from without and from beneath, as Kocher demonstrated on the cadaver. Fractures of the upper end of the humerus are often without any marked displacement; occasionally they are impacted, the fracture surface of the neck being driven into the spongiosa of the head. Supratubercular and Intracapsular Fractures of the Humerus. Fracture of the head of the humerus may be complete or incomplete, the latter in the form of fissures or partial avulsion of the small frag- ments. Fig. 24. , ■ Fracture of the anatomical neck. (Anger.) Fractures of the Anatomical Neck. — Fracture of the anatomical neck is the only typical form, and is less frequent than that of the surgical neck — according to Albert, in the ratio of 1 to 20. It occurs more particularly in older individuals on account of the rarefaction of bone. The head may be impacted and at the same time displaced upward or downward; it may be luxated or completely rotated and lie with the fracture surface against the glenoid cavity. Symptoms. — Swelling and deformity are usually slight. Pain, as in all joint fractures, is marked, and is increased by passive motion. Equally characteristic, according to Kocher, is the immediate, complete, and persistent loss of function. As a rule ecchymosis appears later — at the end of one or two days — beginning on the inner surface of the arm and then spreading in the usual manner. On' palpation the head is found sensitive to pressure. A blow on the elbow produces severe FRACTURES OF UPPER END <>E UPPER EXTREMITY. 51 pain. By abduction ami pressure in the axilla pain and crepitus ran be elicited, especially on rotating the arm. Pain and crepitus are absent with impaction. Sometimes the mobility of the fragment can be felt. \\C examine for flattening of the shoulder, shortening, and the ability to draw the arm downward more easily than normally. The condition is differentiated from fracture of the surgical neck by placing the end of the finger under the acromion and verifying the movement of the tuberosity with the rotated arm. No displacement of the head is palpable as it is in dislocation. Absence of "elastic" fixation of the arm is important for the differential diagnosis from dislocation. Prognosis. — The prognosis of fracture of the anatomical neck is doubtful; complete recovery is rare. Union lias occurred even with complete rotation of the head, as usually some parts of the capsule and periosteum are still attached to it. Ankylosis results more frequently, especially after inflammatory infiltration. If the capsule and the anterior circumflex artery are torn, necrosis of the upper fragment follows. Fig. 25. Fig. 20. Fig. 27. Pig. 25.— Fracture through the tuberosities, with adduction ami impaction front view I. Fig. 26.— The above seen from the inner side, with tin- arm extended. Pig. 27.— Fracture through the tuberosities, with abduction and displacement of the shaft forward and inward. Treatment. — The treatment of supratubercular fracture is occasionally simple. Impacted fractures merely require a sling; later, careful mas- sage and exercise. Bardenheuer claims good results in four to five weeks by the extension method. The tendency of the humerus to be displaced toward the coracoid process is counteracted by outward trac- tion or by a pad in the axilla combined with fixation of the arm across the chest and downward traction. Where intracapsular displacement of a fragment occurs, Kocher ail vises removal of the latter as the most rational and the only successful treatment. In many cases operative interference is required secondarily for necrosis. Above all, the treatment should aim to prevent joint stiffness. For this reason bandages should not be too rigid nor applied too long, and massage and muscular exercise should be begun early and be continued for some time. 52 MALFORMATIONS AND INJURIES OF THE SHOULDER. Infratubercular Fractures of the Humerus. Fracture through the Tuberosity. — Fractura pertubercularis is caused by a blow upon the shoulder from the side, or upon the elbow or shoulder from below and from the side while the arm is adducted. Fracture by adduction is thus frequent (Figs. 25 and 26); as the head is held firmly by the ligaments and capsule, a blow upon the elbow forces the arm inward and backward so that the upper end of the shaft is displaced forward or forward and outward. Fracture by abduction is less common. (Fig. 27 ) Impaction is frequent. (Fig. 25.) Fig 28. Fracture through the tuberosities, with reversal of the head. (v. Bruns.) Fracture of the Epiphysis. — Fracture or separation of the epiphysis is essentially the primal form of pertubercular fracture. Disregarding its occurrence in the newborn, in whom the separation is usually subtu- bercular, it is most frequent from the tenth to the twentieth year. In 49 epiphyseal fractures Bruns saw 21 of the upper end of the humerus. The head and greater tuberosity each have a primary centre and unite in the fifth year to form the epiphysis. The latter unites with the shaft in the twentieth year. Separation of the epiphysis is usually caused by direct violence, such as a fall upon the shoulder; in the newborn by traction upon the arm — solutio brachii. E- < PL, C 0) H 5 CO a CO FRACTURES OF UPPFJl ESI) OF UPPER EXTREMITY. 53 The anatomical conditions found in fracture of the epiphysis namely, the peculiar nodular surface of the upper end of the shaft and the rupture of the periosteum, at times incomplete— are shown some- what diagrammatically in Fig. ~2\). The separation always occurs in the transition stratum between the cartilage and shaft. In older children a wedge-shaped piece of the shaft is not uncommonly torn off with the epiphysis. (Fig. 30.) Symptoms — The symptoms are sometimes trifling. In the new horn, loss of function and pain, which is increased l>y rotation. Displacement is often slight, the curve of the shoulder being normal. In most of the cases the end of the shaft is displaced upward, inward, and forward by muscular traction, forming an angular prominence best seen from the side or above. The skin may he empaled or perforated. Kiistner has noted a marked outward rotation of the epiphysis. Crepitus is com- monly present; in young children the soft cartilaginous crepitus, in older children the usual bony crepitus. Separation of the epiphysis. Periosteum partly intact. (Thudicum.) Diagnosis. — Fracture of the epiphysis in young children is easily over- looked, as the symptoms are insignificant, the shoulder contour normal, the displacement slight. In older children, the evident deformity, the striking deviation of the axis of the shaft forward, the palpable edge of the shaft, and the crepitus are usually so characteristic that the diagnosis is simple. Still the author has seen a few cases in which the differential diagnosis from fracture of the surgical neck was only possible with the .r-rav. The presence of the head in its normal position is against dislocation; if held between the fingers while the arm is rotated, the head does not follow the movements of the latter. The deformity is easily overcome by traction, but returns immediately when the latter ceases. Prognosis. — With proper treatment the prognosis is favorable. Even if accompanied by avulsion of parts of the shaft the shortening is 54 MALFORMATIONS AND INJURIES OF THE SHOULDER. slight if the epiphyseal cap is properly readjusted. If the displacement persists, defects in growth follow which are severe in direct relation to the youth of the patient. In the Tubingen clinic the shortening observed in untreated cases varied from 2f to 51 inches. Treatment. — Proper coaptation of the epiphysis to the shaft is of the utmost importance. A plaster splint suffices for cases without displace- ment. If there is a tendency to displacement the best method is trac- tion or vertical suspension. The latter failing, operative reduction and fixation are indicated. The extension method is also applicable to cases operated upon for malunion. Fracture of the Surgical Neck. — Fracture of the surgical neck (fractura colli chir., fractura subtubercularis) is the most frequent fracture of the upper end of the shaft. It occurs most commonly at Fig. 30. Separation of the epiphysis, with an oblique fragment from shaft. Outward displacement of shaft, (v. Bruns.) the point of transition between the cancellous and spongy bone of the shaft— namely, between the tuberosity and the insertion of the pectoralis major. In the majority of cases it is an abduction fracture produced by direct violence — a blow or fall upon the outer side of the shoulder. It results also from falling upon the elbow and from muscular traction. The line of fracture is usually transverse, rarely oblique; it may extend within the capsule. Transverse and oblique fractures are often serrated or comminuted. Smaller pieces of bone may be chipped off. The sur- faces may be impacted, the lower end being driven bluntly or pointedly — usually the inner edge — into the spongiosa of the upper fragment. The reverse mechanism is rare. (Fig. 34.) Oblique fractures often damage the soft parts; empalement of the muscles is frequent; rupture of the biceps tendon and injuries of the nerves and vessels are rare. With marked displacement of the fragments the soft parts — deltoid and biceps tendon FRACTURES OF UPPER KM) OF UPPER EXTREMFTY. 55 — may become interposed. The skin may be empaled or perforated. It' the lower fragment is freely movable, it may he displaced inward by the pectoralis or latissimus, or upward by the deltoid; the upper frag- ment is drawn slightly outward by the teres minor. The displacement, however, is often influenced by the nature and direction of the violence in such a way as to prevent the typical action of the muscles. Symptoms. — Abduction being the most frequent position of the lower fragment, the symptoms are very similar to those of dislocation: flat- tening of the shoulder with a depression at about the deltoid insertion. Loss of function is evident. Pain and swelling are moderate. Short- Fig. 31. Fig. 32. Separation of the epiphysis, with malunion, dating from first year. Aged twelve years, (v. Brims.) Impacted fracture of the humerus through the tuberosities. (R. W. Smith.) ening is usually noticeable — 1 to 2 inches. The arm admits of free passive motion, and in the absence of impaction false motion is easily obtained by holding the head between the fingers and moving the arm. At the same time crepitus is felt if the ends are not separated by inter- posed muscle. In the axilla the lower fragment is palpable and rotates with the arm, while the head is felt to be in place. Bearing these symptoms in mind, the condition cannot be confused with dislocation. An accurate determination of the level of the fracture line, however, may be difficult if the soft parts are thick. The x-ray 56 MALFORMATIONS AND INJURIES OF THE SHOULDER. has frequently convinced the author of error in this respect to the extent of several fingers' breadth. Prognosis. — The prognosis is usually favorable; union is complete in from four to six weeks. Pseudarthrosis is rare. So are severe compli- cations, such as suppuration of the joint, paralysis of the nerves of the arm, or gangrene from compression, or injury of the large vessels of the axilla. The mobility of the arm may be permanently impaired. Disregarding the direct involvement of the joint by supratubercular fissures, its proximity to the fracture is sufficient to explain the traumatic irritation and the stiffness that follow, just as from simple contusions. Occasionally motion is limited in certain directions by exuberant callus or malunion with angular deformity, as in adduction or with rotary displacement. Fig. 33. Fig. 34. Impaction of the head of the humerus into the shaft, with splitting off of the tuberosities. (R. W. Smith.) Fracture of the surgical neck, with impaction, (v. Bruns.) Treatment. — The treatment of fracture of the neck without displace ment is simple: moulded strips, starch bandages, an axillary pad, and a sling are sufficient. The latter should support the wrist only, not the elbow, to permit extension of the arm by gravity. The reduction of marked displacement will require appropriate downward or lateral trac- tion or pressure. The splint should exert continuous traction. For severe cases the horizontal extension method, as recommended by Bar- denheuer, is most satisfactory. For ambulant cases the two-strip splint may be combined with extension as for supracondyloid fractures of the lower end of the shaft (which see). In general the author prefers vertical FRACTURES OF UPPER END OF UPPER EXTREMITY. 57 Suspension in the Literal position. Its action is certain if sufficient weight is used. The general rule for extension by weight applies here Pig. 35. Fig. 36. Fracture of the upper end of the humerus. Note hand, forearm, and elbow bandaged; axillary pad and strap. (Scudder on Fractures.) as in all fractures — namely, to use heavy weights at first (Bardenheuer advises twenty pounds in the first two days) to overcome muscular contraction, and later only sufficient to maintain the fragments in posi- 58 MALFORMATIONS AND INJURIES OF THE SHOULDER. tion. In suspension the weight acts only when it is heavier than the arm; the latter in the adult weighs about seven and a half pounds, according to Harless. Clark believes that extension is less effectual in ambulant cases. Traction is removed for the recumbent cases in from eight to fourteen days; an extension strip splint is applied and the patient is made ambu- lant. The ambulant treatment is better from the outset if the tendency to displacement is slight or if for any reason the recumbent position is inadvisable — namely, in the case of elderly subjects. Operative interference is rarely necessary; axillary complications should receive appropriate treatment. Exceptionally, irreducible frac- Fig. 38. Fracture of the upper end or shaft of the humerus. Posterior view. Note bandage to forearm and elbow ; axillary pad and strap. Note shape of axillary pad. (Scudder on Fractures.) tures will require incision and suture. Rehn cites 2 such cases with good results. The author advises operation in all compound fractures with severe damage of the soft parts, even if resection is unnecessary. Operation may be required secondarily to excise a projecting portion of the lower fragment limiting motion, or to do an osteotomy of the fracture with secondary suture. At the present time we make operation dependent upon the findings of the x-raj. The incision should have regard for the later function, as emphasized by Kocher, and if possible be made at the anterior deltoid margin. Fracture of the neck as the frequent complication of dislocation of the shoulder will be discussed with shoulder dislocations. FRACTURES OF UPPER ESP OF UPPER EXTREMITY. 59 Fracture of the Tuberosities. Fractures of the .tuberosities alone ni.iv be incomplete or complete; they are usually combined with other injuries. The greater tuberosity is broken off most frequently, it may be torn or knocked off in connection with dislocation of the shoulder. Deuerlich collected 17 cases of this sort. The tuberosity may be torn off entirely; or only the two anterior facets or the posterior facet. (Gurlt.) Longitudinal fissures have been seen. Usually the fracture line begins at the level of the anatomical neck; exceptionally a piece of the shaft may be torn off. Interposition of the biceps tendon has been found in a few cases. As a rule, the tuberosity is drawn upward and outward from 1 to 1\ inches by the Fig. 39. Fig. 40. Fracture at upper end of the humerus. Note hand, forearm, and elbow bandaged ; axillary pad and strap, plaster-of-Paris shoulder-cap, sling. (Scudder on Fractures.) Fracture at upper end of the humerus. Arm and elbow bandaged. The axillary pad and shoulder-cap in position. Application of cir- cular bandage to trunk and shoulder. Sling not shown. (Scudder on Fractures.) external rotators. Exceptionally the tuberosity is driven between the head and shaft like a wedge. The cause is ordinarily a fall upon the shoulder or outstretched hand, rarely the forced action of the outward rotators in throwing or hurling objects. Symptoms. — In isolated fracture of the tuberosity the arm is sublux- ated forward and can be rotated inward abnormally. Outward rotation is impossible actively, but possible passively. The shoulder appears broader from before backward; the acromion projects sharply; the tuberosity is displaced downward and backward from the latter, and forms a distinct prominence separated from the head by a palpable groove. It is tender on palpation and gives crepitus if moved. Asso- 60 MALFORMATIONS AND INJURIES OF THE SHOULDER. Fig. 4 ciated with dislocation of the shoulder it is usually first recognized during reduc- tion, and may hinder the latter if it lies in the glenoid cavity; it may be evidenced after reduction by a surprising tendency to reluxation. Union occurs, as a rule, with a certain amount of displacement, giving the bone the forked form of the upper end of the femur. (Fig. 41.) The broadening of the upper end of the hume- rus may impair its function, especially rotation and abduction. Treatment. — The effort should be made to replace the fragment by immobilizing the arm in abduction and outward rota- tion. With Kocher the author believes the best method is to suture or nail the fragment back in place. Isolated fracture of the lesser tuberosity is rare. Gurlt cites 3 cases. As an ac- companiment of dislocation, produced by Old fracture of the greater tuber- the action of the subscapular muscle, it is osity. Arthritis deformans f the somewhat more frequent. The fragment dislocated head. tv. Bruns.) . . , , ,, . • 1 » ■ may be palpable to the inner side of its normal position and give crepitus. Inward rotation is impaired; the biceps tendon may be torn and increase the functional disturbance. DISLOCATIONS OF THE SHOULDER. "'Dislocations of the shoulder are the most frequent of all dislocations: Kronlein gives the relative frequency as 51.7 per cent.; Gurlt, 52.4 per cent.; Bardenheuer, 54 per cent.; French authors, collectively, 55 per cent. This frequency is easily explained by the free mobility; the exposed position; the anatomical structure of the joint, whose glenoid surface is three to four times smaller than the surface of the head; and by the long lever-arm as represented by the entire extremity. The dislocation is most common in middle and advanced life, between the fortieth and sixtieth year, and very rare in childhood. Men are affected four to five times more often than women, on account of greater exposure to injury in their occupations. Displacement of the head upward is prevented by the acromion, the coracoid process, and the coracoacromial ligament-, and is hardly con- ceivable without fracture of these structures; displacement downward is opposed by the resistance of the capsule reinforced by the long head of the biceps, hence it is possible for the head to leave the cavity only forward or backward. Dislocation forward occurs much oftener than in the opposite direction; the material in Brims' clinic gives the ratio DISLOCA TIONS OF THE SHOULDER. Gl of 98 to 3. According to the level at which the head lodges, various subvarieties may be classified. To distinguish between complete and incomplete dislocation is of little practical importance, the latter form being rare. The author recommends the following classification as most practical: I. Luxatio anterior or prseglenoidea : 1. Subcoracoidea. 2. Axillaris or prseglenoidea inferior. 3. Prsescapularis. 4. Infraclavicularis. II. Luxatio posterior or retroglenoidea: 1. Subacromialis. 2. Infraspinate or retroglenoidea inferior. The large majority of dislocations of the shoulder are typical, being determined by the integrity of the strongest parts of the capsule, espe- cially the coracohumeral ligament. Exceptionally, from extensive laceration of the capsule or avulsion of the tendon insertions and bony protuberances, atypical displacements of the head occur, which Kocher, following Bigelow, has termed " irreg- ular " dislocations in contrast to the "regular" forms. They belong among the forward dislocations and will be described with them. Forward (and Downward) Dislocations of the Shoulder. Subcoracoid Dislocation. — This is the most frequent and therefore most important dislocation of the shoulder. The head is displaced for- ward and inward and lies beneath the coracoid process. (Fig. 42.) In some instances the cause is direct: a blow from behind or a fall — e. g., against the edge of the stairs; more frequently indirect — a fall upon the arm outstretched behind or upon the hand. In a large number of cases it results from hyperabduction, the greater tuberosity being pressed against the upper margin of the cavity, the surgical neck against the acromion, the latter thus acting as a fulcrum. The long lever-arm, the entire extremity, pries the short arm, the head, out of the socket, with laceration of the lower front part of the capsule. The dislocation is therefore at first downward and forward; secondarily the arm drops and the head is pushed up beneath the coracoid process. In experimental dislocation hyperabduction alone is usually not sufficient, but must be combined with rotation. So in the various causes of production, such as a fall upon the hand or being dragged by a horse while holding the reins, there is commonly a rotary factor. Exceptionally, muscular action is the cause, as in throwing, or by a false thrust or swinging blow, as in whipping, or epileptic or eclamptic attacks. Axillary Dislocation. — The head lies upon the so-called facies sub- glenoidea, the surface of the scapula beneath the glenoid margin facing downward and formed by the lateral border curving backward about f inch. This surface is sufficiently broad to form a support for the head. In the causation hyperabduction plays the chief part; any 62 MALFORMATIONS AND INJURIES OF THE SHOULDER. Fig. 42. secondary upward movement of the head beneath the coracoid process is prevented by the intact anterior portion of the capsule. Exceptionally the arm does not drop secondarily, giving the so-called luxatio axillaris erecta of Middeldorpf, the humerus being fixed in vertical elevation. Finckh reports one "erect" case in 201 dislocations forward; Kronlein, 3 in 207. By the continuation of the force in the direction of the abducted arm the head is driven further down against the chest. In some instances the dislocation was pro- duced by violent wrenching of the elevated arm in the attempt to save one's self in falling from a height. The subcoracoid and ax- illary forms represent 92 per cent, of forward disloca- tions; the other forms are extremely rare. In Finckh's 201 cases 8 were prescapu- lar, 2 infraclavicular. Both of the latter may be regarded as an accentuation of the inward displacement of the head in preglenoid disloca- tion. In prescapular dis- location the head lies in the subscapular fossa between the subscapularis and the scapula, or it may perforate the muscle. The infrascap- ularform, in which the head lies close beneath the clavi- cle to the inner side of the coracoid process, presup- poses extensive laceration of the capsule and muscular attachments by great vio- lence, such as a fall from a horse. The head may project forward and lie beneath the skin in the perforated pectoralis, as noted by Tillaux; or it may push the clavicle forward and be wedged between the same and the first rib until it pro- jects an inch above the clavicle. Anatomical Findings of Forward Dislocation. — Extravasation of blood and ecchymosis may be more or less extensive about the joint, as indicated by Malgaigne, Pitha, and others. The head lies in front of or partly beneath the neck of the scapula, covered by the sub- scapularis or embedded in its torn fibres beneath the coracoid process between the glenoid cavity and the thorax. (Fig. 43.) The capsular rent is at the lower front margin of the joint between the subscapu- Subcoracoid t inn of the shoulder, (v. Brims. DISLOCATIONS OF THE Silo I LI) Ell. 63 . laris and the origin of the long head of the triceps; exceptionally the capsule is torn from the head between the insertions of the teres minor and subscapularis. In single instances dislocation has Keen seen with- out laceration of the capsule. The position of the head and limb is determined by the integrity of the upper front part of the capsule and the coracohumeral ligament, the latter being stretched tightly between the upper margin of the cavity and the lesser tuberosity. Fig. 43. For this reason all the muscles can be severed on the cadaver without affecting the abnormal fixation; on dividing the still intact and tense parts of the capsule the elastic fixation and typical position of the humerus are lost, as noted by Busch. The long biceps tendon running obliquely from the top of the glenoid cavity to the upper arm may be stretched or torn or be caught around the neck of the humerus. The great vessels lie close to the inner surface of the dislocated head. The violence may not only tear the capsule, but also damage the adjacent soft parts and bones. The muscles reinforcing the capsule and the tendons of the subscapularis, teres minor, supra- spinatusand infraspinatus, are not infrequently lacerated or torn off with a lamina of bone. The fur- ther the head advances inward beneath the coracoid process, the more likely is the greater tuberosity to be torn off. Rarely the lesser tuberosity is torn off by the sub- sea pularis. Chipping of the glenoid margin and fracture of the anatomical or surgical neck are fairly frequent complications of shoulder dislocations. (Fig. 44.) Fractures of the neck are supposed to result secondarily from continuation of the violence. Thamhayn collected 68 cases of this kind (1868). Fractures of the acromion or coracoid process are ex- ceptional. For complications of the great vessels, see page 20. Injuries of the adjacent nerve-trunks, especially of the circumflex nerve, the motor nerve of the deltoid, by pressure or contusion (rarely lacera- tion) are more frequent (page 24) ; the nerves may be involved second- arily in the constriction produced by cicatrices following non-reduc- tion. Compound dislocations in the strict sense of the term occur very rarely in severe accidents — dragging, railway, and machinery accidents. Subcoracoid dislocation. (Anger.) 64 MALFORMATIONS AND INJURIES OF THE SHOULDER. Fig. 44. ( rraroifi Symptoms and Diagnosis of Forward Dislocations. — The deformity of subcoracoid dislocation is often so marked as to be recognizable through the clothing. The head generally inclines to the affected side; the arm is abducted to about 20 degrees from the chest-wall, appears lengthened, and is usually supported by the other arm. (Fig. 42.) The arch of the shoulder is more angular and the acromion projects sharply. The deltoid slopes straight from the acromion or sinks in, giving an indented appear- ance to the arm at its insertion. Beneath the acromion the tissues can be pressed into the hollow of the glenoid cavity. The axis of the arm does not point to the acromion, but to Morenheim's space, where a prominence is seen and felt, recognizable as the head, especially on rotating the arm. The abducted elbow, in the pathognomonic position of " elastic" fixation, cannot be adducted. Axillary dislocation differs from the above in the lower position of the head, which is easily felt in the axilla; the abduction, indentation, and apparent lengthening are more marked. In pre- scapular dislocation the head lies further toward the median line than in the sub- coracoid form and can be felt in the axilla only by abducting the arm strongly. In infraclavicular dislocation the outline of the head is visible and palpable beneath the clavicle to the inner side of the cora- coid process; the arm is so adducted that the finger can hardly be forced into the axilla; Bardenheuer, however, saw 2 cases in which the arm was horizontal — " horizontal dislocation." Complications may modify the deformity; with fracture of the neck elastic fixation is absent and the displaced head does not rotate with the shaft; crepitus may be elicited by passive motion. A separated tuberosity can sometimes be felt in the glenoid cavity; the arm admits of wider motion and has a tendency to become "reluxated" after reduction. Of less diagnostic importance is the extravasation, which may be entirely absent or extend to the fingers and to the crest of the ilium. Exceptionally, pressure upon the veins may produce stasis, cyanosis, or subsequently oedema. Numbness and tingling in the fingers from compression of the nerves are reported frequently; for the symptoms of severe lesions of nerves and vessels, see the respective chapters. Supracoracoid dislocation is an atypical form, of which only 20 cases are known in the literature. From experiments on the cadaver, Busch regards simultaneous fracture of the coracoid as essential to its pro- duction. Mayo Robson saw a case without the latter, but with a longitudinal fracture of the tuberosity. The cause was commonly an upward blow upon the abducted elbow; in Busch's case it was violent upward traction upon the arm and a simultaneous blow of a hoof Dislocation of head of the humerus associated with fracture. (Bryant.) DISLOCATlnys OF THE SHOULDER. 65 upon the shoulder. Albert reports a case <>t* bilateral dislocation resulting from ;i runaway accident. In these cases the deltoid is not indented; the arm is adducted and shortened; mobility is slight and possible only backward and forward. The empty glenoid cavity is palpable from behind. The pathognomonic sign is the presence of a rounded prominence between the acromion and coracoid process; it pushes up the deltoid and is most noticeable on drawing the arm backward. Fracture of the coracoid may he recognizable by crepitus. For reduction, Bardenheuer advises backward elevation of the arm and direct pressure upon the head. The very characteristic symptoms of preglenoid dislocation make diagnosis simple in recent cases; -welling and extravasation, however, may mask the angularity of the shoulder and the emptiness of the glenoid cavity. The prominence beneath the coracoid may be slight, particularly in obese individuals, and especially if the head lies deeper in the subscapular fossa; it can then be felt through the axilla beneath the pectorals. In doubtful cases and for the determination of compli- cating bone lesions the .r-ray is valuable. Prognosis. — In uncomplicated cases with proper reduction and treat- ment the prognosis of preglenoid dislocations is favorable; as a rule, full use of the arm is regained in from four to eight weeks, especially in children, who recover rapidly and completely if active motion is begun early; in old individuals a certain amount of stiffness per- sists and may lessen their working ability from 25 to 50 per cent. Exceptionally the dislocation becomes chronic. Naturally complica- tions modify the prognosis, such as extensive laceration of the liga- ments or capsule; tear fractures; lesions of the nerves or vessels, especially stretching or rupture of the circumflex with the resulting paralysis and atrophy of the deltoid. To prevent a delusive prog- nosis Helferich therefore advises electrical test of the deltoid after reduction. Forward dislocations are rarely irreducible primarily; the infraclavicular form is an exception, and in spite of its infrequeney several cases are known in which primary operation — even resection — was necessary. Primary irreducibility is usually due to complications. In 18 cases Schoch notes as causes: stretched capsule, 1; fracture of the greater tuberosity, 2; fracture of the neck, 12; muscular interposition, 2; cause unknown, 1. Kocher found fracture of the tuberosity in 5 of 8 cases operated on; Brims found the same in several instances. If for any reason reduction fails, "traumatic reaction" supervenes, but more slowly than after reduction, and more or less functional disturbance persists. The latter will be considered later under old shoulder dislo- cations. Treatment of Forward Dislocations. — The intact parts of the capsule, which are put on the stretch at the moment of dislocation, and which hold the head in its abnormal position, form the greatest hindrance to reduction. The anterior fibres of the coracohumeral ligament form a tense band in subcoracoid dislocation which binds the head against the front margin of the cavity; their relaxation is therefore essential for Vol. III.— .5 QQ MALFORMATIONS AND INJURIES OF THE SHOULDER. reduction. A further hindrance is produced by the muscles which draw the head upward and inward; naturally they have to be considered, although their influence varies greatly with the individual. In addition to these constant factors there may be interposition of ruptured portions of the capsule or tendons, displacement of the biceps tendon, or perfora- tion of the subscapularis by the head. It would seem that many authors underestimate the hindrance caused by muscular contraction or tension, possibly in view of Busch's experiments upon the cadaver. Such experiments indicate only the mechanical action of non-contractile tissues; the influence of muscular tone is estimated accurately only on living subjects. How great this influence is seems to the author to be demonstrated by the fact that the larger number of dislocations resisting reduction are easily overcome under deep anaesthesia. The reduction of recent dislocations should be tried first without anaesthesia; no rule can be laid down as to how far to carry the attempt; in the absence of serious general counterindications to anaesthesia dread Fig. 4.-, Kocher's method of reduction by manipulation; first movement, outward rotation. (Geppi.) of the latter should not delay reposition, as it is made more and more difficult by the increasing infiltration of the soft parts. Formerly the various methods of reduction were classified as reposition by impulsion; by leverage; by rotation. They may be brought into two groups, accord- ing as the head is (1) rotated laterally through an arc (the method of Scninzinger, Kocher, and Gordon); or (2) simply pushed outward (Avicenna, Cooper, Konig, and others). Of the first, Kocher's rotation- elevation method is now regarded by many as the rational one for sub- coracoid dislocation, as it takes the anatomical relations most fully into account and is effected without great force or pain. The steps are as fol- lows: the abducted elbow is adducted slowly but forcibly against the body and drawn slightly backward; with one hand on the elbow and the other holding the wrist of the semiflexed arm, the upper arm is rotated outward slowly but forcibly until the forearm points laterally (Fig. 45); with the DISLOCATIONS <>r THE SHOULDER. r>7 arm still firmly rotated outward the elbow is raised directly Forward as far as it will go (Fig. 40); in this position the forearm is swung slowly inward across the chest to the other side — that is, the arm is rotated Fig. 4ti. Kocher's method of reduction; second movement, elevation i>f elbow. (Ceppi.) inward, and reduction usually follows with a snap. (Fig. 47.) By adduction the upper part of the capsule is put on the stretch, the head is thereby pressed against the joint-margin and forms a firm point of Fig. 47. Kocher's method of reduction: third movement, inward rotation and lowering of elbow. (Ceppi.) support for the following outward rotation; this latter opens the rent in the capsule; by elevation the intact upper part of the capsule and coraco- humeral ligament are relaxed, the lower torn portion is put on the 68 MALFORMATIONS AND INJURIES OF THE SHOULDER. stretch, and the head levered into the cavity outward upon the fulcrum so formed. The reduction is completed without force by simply rotating the arm inward and lowering it. The efficacy of Kocher's method is attested by Power, who in 129 cases succeeded, without an anaesthetic, 98 times in the first attempt, 6 times in the second, 8 times in the third, failed in only 7 — a total of 113 without anaesthetic, 6 with; v. Bergmann in more than 200 cases had no failures. There are instances, however, in which Kocher's method fails, and in which Mothe's or Cooper's succeeds; further, it has caused fracture of the humerus not a few times, according to Kocher himself 3 times in 28 cases, a fact easy to understand when one considers the enormous leverage of the semi- flexed forearm during rotation. In Schinzinger's method the operator stands in front of the patient, seizing the elbow with his corresponding hand and the wrist with the other, adducts the semiflexed arm firmly against the chest and then rotates outward, an assistant meanwhile holding the scapula; the assist- ant now presses both thumbs against the anterior border of the axilla and so holds the head against the glenoid margin, while the operator completes the reduction by rotating slowly inward. In contrast to Kocher's method, it has the disadvantage of not relaxing the upper part of the capsule and the coracohumeral ligament. The direct impulsion method of Avicenna is effectual only in recent cases presenting slight resistance; the shoulder being held, the arm is slightly abducted and the operator then makes direct pressure in the axilla upon the head with the fingers of the corresponding hand, or with the thumbs, with counterpressure upon the acromion. Konig recommends Mothe's old hyperabduction method: the shoulder is drawn firmly back- ward and downward, the body toward the other side, by two cloth bands, one passed over the shoulder and the other around the chest from the other side; the arm is then abducted and elevated slowly and steadily while an assistant presses the head directly toward the socket; this is followed by quick adduction and inward rotation of the semiflexed arm. Cooper's lever method aims to produce a fulcrum in the axilla: the patient lies upon the floor, the operator's foot is placed in the axilla and direct traction is made on the arm; or the operator stands upon a stool, places his knee against the axilla from behind, fixes the shoulder with one hand, and makes direct downward traction upon the arm. The method is effectual, but is painful and liable to lacerate the vessels and nerves, an accident to be avoided, especially in old individuals. Occa- sionally it has proved indispensable, and may be tried, possibly with appropriate rotation, in cases in which Kocher's rotation fails. Bruns combines Mothe's method with gentle leverage by adducting the arm against the fist held in the axilla. With Konig, the author has every reason to be satisfied with the results of this method. Riedel has recently suggested a method which he tested in about 150 cases: the arm is drawn with a forcible jerk toward the other side of the pelvis, the muscles being completely relaxed under deep anaesthesia. Instead of using anaesthesia, Stimson overcomes the muscular resist- DISLOCATIONS OF THE SHOULDER. 69 ance by continuous weight-extension; the dislocated arm is lowered through an opening cut In a canvas coi and a weight attached. (Fig. 48.) Hofmeister modifies this method by placing the patient on the sound aide and suspending the arm vertically by means of a pulley, weight, and continuous traction. The author has had such successful results with Stimson's method that he employs it regularly. It is particularly useful for the practising surgeon in dispensing with a trained assistant and obviating the danger of further injury. A cloth loop is bound tightly along the entire arm and then weighted with 10 pounds, 10 pounds being added at intervals of from one to two minutes up to 40 pounds; in from five to fifteen minutes the head advances outward to the level of the cavity and either slips in itself or is easily forced in by Fig. 48. Reduction of anterior dislocation of the shoulder. (Stimson.) seizing the wrist and adducting the arm against the fist held in the axilla. In 30 dislocations remaining unreduced up to the fourteenth day anaes- thesia was required to relax the muscles in only 3 of the cases reduced by this method in spite of the fact that previously many futile attempts had been made, chiefly in the same direction, with and without anaesthesia. The method differs from the old traction methods in requiring less force. Recently Roloff reduced several cases by gradual manual traction. With the exception of the methods of Schinzinger and Kocher, which are specially adapted for subcoracoid dislocation, all of the above methods are applicable to forward dislocations, certain modifications being advisable according to the position of the head. For example, 70 MALFORMATIONS AND INJURIES OF THE SHOULDER. \ in infraclavicular dislocation Konig advises backward traction upon the arm and counterpressure against the scapula. For this form Kocher recommends that his rotation method should be tried first, with the elbow pushed backward in order to give the head a firm point of support against the axillary border of the scapula. For axillary dislocation he employs Mothe's method, in addition rotating the abducted arm outward. Traction by weight is useful for all dislocations of the shoulder, even the posterior varieties. The line of traction is varied by moving the patient in the appropriate direction beneath the pulley. As the head often slips back gradually into Vm. 49. the cavity without a snap, re- duction should always be veri- fied by the absence of deform- ity, the ability to adduct the arm and place the hand upon the other shoulder, and by the absence of elastic resistance. An irreducible dislocation demands immediate operation as the latter is easier and more successful if not delayed; resec- tion should be considered only as a last resort. Subsequent treatment con- sists in immobilizing the arm in a sling or a Velpeau dress- ing. Massage and gentle pas- sive motion are begun at the end of eight days. Abduction should be avoided at first. This period of rest of eight days is sufficient to determine the functional result. For this reason Thiem recommends that motion and massage should begin in uncomplicated cases immediately after reduction, and should be repeated as often as possible daily. In the first few days the joint is compressed with the hands during motion. For many years the author has followed Thiem's principles in the after-treatment of simple dislocation of the shoulder, and so far has never seen reluxation or habitual dislocation follow; on the contrary, the usefulness of the joint was often regained at an early period, whereas in the author's previous experience more or lf j -- pronounced stiffness was always to be feared. The complications mentioned demand appropriate measures. Deltoid paralysis requires early electrical treatment. Even compound disloca- tions of the shoulder can recover without much functional disturbance, as shown by Nussbaum, Soderbaum, and others. Strict antisepsis and the reduction of the head if possible are the requisites. Severe com- minution, extensive avulsion of the muscular attachments, or drying up of the cartilage requires resection, the results of which, according Subeoraeoid dislocation with fracture of the neck. Reversed head adherent to the 9capula. (v. Brans.) DISLOCATIONS OF THE SHOULDER. 71 to Uhde, arc good. Simultaneous fracture of the neck calls first for the reduction of the head by direct pressure and, the author would suggest, with the aid of traction by weight. Thamhayn was successful in 22 of 68 cases. If reduction is not possible, operation with or without suture of the fragments is the ideal procedure; Schoch reports 10 excellent results, 1 fair result, and 1 requiring later resection among 12 cases. If reduction by operation is not possible, the head should be removed. If operation is counterindicated by age or general condition or is refused, Cooper recommends placing the end of the shaft in the glenoid cavity and encouraging the formation of a new joint by early motion. The head can he removed later if it produces disturbance. The attempt to reduce the dislocation after waiting from six to ten weeks for the fracture to heal can hardly have many advocates at the present time. Backward Dislocation of the Shoulder. This form of dislocation is rare. In 207 dislocations of the humerus >een by Kronlein in Langenbeck's clinic there was only one of this sort. Finckh in v. Brims' clinic saw 201 dislocations forward and only 5 backward. Busch saw a case in a child of ten years. Subacromial dislocation signifies that the head lies above and behind the joint beneath the. acromion upon the neck of the scapula; if it lies further down in the infraspinate fossa beneath the spine of the scapula, the dislocation is called infraspinate. The latter form is even more rare. Retroglenoid dislocation is generally the result of a blow upon the shoulder from in front; indirectly it is produced by a fall upon the outstretched hand or upon the elbow held forward; also sudden forcible elevation of the elbow or forced muscular action, as in throw- ing or in epileptic attacks. According to Malgaigne, 8 of 29 cases of retroglenoid dislocation were caused by convulsions. Considerable force is required to produce this variety, as the capsule is reinforced by the outward rotators at the point where the head perforates. Engel's experiments on the cadaver show that it occurs only after the insertion of the subscapularis on the lesser tuberosity is torn off and a rent is made in the capsule close to the posterior margin of the cavity. Infraspinate Dislocation. — For the production of this form it is necessary that the arm should be flexed sharply and that a blow strike the elbow as it is held fonvard, or that the arm be rotated forcibly inward, as in falling forward upon the elbow. The capsular tear is in the lower posterior quadrant, the greater part of the posterior circumference remaining intact and by its tension preventing ascent of the head. The head lies in the infraspinate fossa pointing backward and inward; the lesser tuberosity is pressed firmly against the glenoid margin and held there chiefly by the posterior portion of the coracohumeral ligament; the cavity is covered by the anterior wall of the capsule. Symptoms. — The shoulder is broadened, the arm abducted and directed somewhat forward, and rotated inward. Beneath the acromion there is usually a distinct depression and in front of the joint a pit which 72 MALFORMATIONS AND INJURIES OF THE SHOULDER. appears to be divided into a larger outer and a -mailer inner half by a band running from the coracoid process to the arm. (Busch.) The head is usually recognizable as a rounded prominence in the infra- spinate fossa, especially by rotating and moving the arm. Diagnosis.— The diagnosis is not difficult. The axis of the humerus points to the outer side of and behind the cavity, particularly as seen from the side. Fig. 51 . Prognosis.— The prognosis is favorable. Reduction is almost always easy even after months; in a case of Sedillot's at the end of a year. On the other hand, recurrence is not infrequent, habitual dislocation being often seen as the result of backward dislocation. To reduce infraspinate dislocation, Kocher recommends: 1. To increase the inward rotation of the upper arm in the existing position of flexion in order to force outward Fig. 50. Fig. 51. Posterior dislocation (subacromial, subspinate). the head held by the stretched capsule, analogous to outward rotation in subcoracoid dislocation. 2. Abduction to relax the coracohumeral ligament and free the head from the posterior margin of the cavity. 3. Traction to put the lower part of the capsule on the stretch. 4. Out- ward rotation to complete the reduction, after which the arm is adducted. Reduction is sometimes easy by abducting the arm to a horizontal with traction, then rotating outward and adducting with direct pressure upon the head. Subacromial Dislocation.— Although by no means frequent, this variety is more common than infraspinate dislocation, and is produced by a fall upon the front of the shoulder or a blow in the opposite direc- tion. The head is not displaced so far, especially to the inner side, as in the preceding form. The anatomical neck lies upon the glenoid margin; the anterior fibres of the coracohumeral ligament are tense. The lesser tuberosity is often torn off by the tendon of the subscapularis. Reduction is usually easv. Forced abduction or flexion is liable to DISLOCA TIONS OF THE SH0ULD1 7;} overstretch the lower part of the capsule. Simple traction in the given direction is often sufficient, and the only part of the capsule on the stretch is relaxed by inward rotation. Koelier recommends 1 I forcible inward rotation in the given flexion position of the arm; 2) traction in the same given direction of the arm, then outward rotation and exten- sion. In one instance Malgaigne was unable to effect reduction until the elbow had Ween drawn backward. In view of the author's succ< - with weight-extension in forward dislocations it should be tried here. Old Dislocations of the Shoulder. Old dislocations are observed most frequently in the shoulder, and chiefly the forward variety — 98 per cent., according to Smital and Finckh. Old bilateral dislocations have also been reported. (Lister, James.) Although it is true that the majority of old dislocations of the shoulder are due to the indolence of the patient, who uses household remedies or is satisfied with the advice of a charlatan, still, in view of the material coming under our observation, it would not be proper to suppress the fact that a lamentable percentage is referable to surgical neglect, perhaps as the result of an uncertain diagnosis due to marked swelling, perhaps faulty technic, inadequate assistance, or improper anaesthesia, all of which happens not infrequently, and although it is far from the author's purpose to criticise the attending surgeon, never- theless it must be regarded as an error to content one's self and the patient with the assurance that nothing further can be done until the traumatic reaction has subsided, instead of consulting a more expe- rienced colleague or sending the patient to a hospital. When is a dislocation old? It is hardly possible to give a certain time. Still, in general a dislocation may be regarded as old after from four to six weeks, as at that time all reaction has disappeared in the injured area. Anatomy. — Following resorption of the extravasated blood and the disappearance of swelling, more or less connective tissue forms about the dislocated head like a new capsule and soon entirely covers the tear in the old capsule. There are irregularities in the atrophying cartilage of the head and irregular bony growths if the muscular attachments have been torn off. The anterior glenoid margin may be indented where it presses against the head. At the point where the head rubs against the scapula the irritation of the periosteum is followed by thickening and the formation of new cavity, whereas the old cavity disappears and is levelled off like the alveolus after extraction of a tooth; it may even become convex. (Fig. 52.) Long before this event the old capsule has contracted concentrically over the empty cavity until it lies as a fibrous mass upon the joint-surface and becomes adherent, so that even at a period when the form of the cavity is still normal it may completely pre- vent reduction. The cartilage meanwhile mav remain unchanged for months. The new capsular space communicates with the old one through a more or less narrowed opening, or may be separated from 74 MALFORMATIONS AND INJURIES OF THE SHOULDER. it entirely if the head is greatly displaced. Laminated growths of bone are sometimes produced by ossification of the connective tissue extending from the coracoid process or the head, or the ossification may be limited to single ligaments. The oc- Fig. 52. casional adhesion which takes place between the vessels and the dislocated head has been mentioned. Kocher saw a case in which the circumflex and axillary arteries were adherent to the wall of the newly formed cavity. The muscles running from the thorax and scapula to the dislocated head are correspondingly shortened. Symptoms and Diagnosis. — The degree of mobility of the head in its new position, namely, whether there is ankylosis or a nearthrosis, depends chiefly upon whether the arm is moved from the outset or not. The degree of functional impairment varies in like manner. Every surgeon in active practice has seen cases in which the impairment was slight; still, Pitha's statement that "an unre- duced dislocation of the shoulder usually produces a lasting and very sad deformity of the extremity, and compromises the earning ability of those dependent upon hand work," applies to the majority of cases. Abduction is usually limited in spite of the compensatory mobility of the scapula. The diagnosis, in contrast to recent cases, is aided by the absence of swelling. Abnormal mobility cannot occasion confusion. Sometimes the radiograph gives important details as to treatment, less so as to the diagnosis. Prognosis. — The prognosis as far as it concerns reduction depends upon the time that has elapsed and the anatomical conditions in the individual case. According to Finckh's statistics from v. Bruns' clinic, reposition in uncomplicated cases is always possible up to the fourth week; from the third to the ninth week successful in about 77 per cent, of the cases, and impossible after fourteen weeks. Further than this it is not possible to determine the period of reducibility; in individual instances reduction was effected after months; Simon was successful after twenty- one months. The irregular dislocations generally become firmly adherent and irreducible at an earlier period; many of the dislocations to the inner side of the coracoid process were irreducible after a few weeks. Old dislocations have acquired an evil reputation on account of the accidents resulting from forcible attempts at reduction, particularly injuries of the large vessels and nerves and fracture of the humerus. Flaubert found in 1 case that the last four trunks of the brachial plexus had been torn completely from the spinal cord; the patient died eighteen days after reduction. For injuries of the vessels compare page 20. Newly forme*) cavity below the coracoid process in an old dislocation, (v. Bruns.) DISLOCATIONS OF THE SHOULD EB. 75 Treatment. — The treatment of old dislocations requires great care and individualization. If possible, ;i skiagram should be obtained to determine t In* existence of exostoses, splinters, etc., which under circum- stances can damage the vessels during reduction. Naturally reduction should be attempted only when there is a prospect of benefit. The older the dislocation and the freer the mobility, the less indication there is for interference. The age and general condition of the patient, par- ticularly with regard to the possibility of secondary injuries, are to he considered; and finally in accident cases arises the question as to whether, considering the mental attitude of the patient, the surgeon can expect that the latter will give the aid in the mechanical treatment necessary to obtain better function than already exists, for if ankylosis follows reposition the surgeon might as well have saved himself the trouble. All the methods described in the treatment of recent dislocations, except those of direct pressure, are applicable; but from the nature of the case greater force is usually required and anaesthesia is almost indis- pensable. The first step is the mobilization of the head by stretching and breaking up the adhesions. This is accomplished by the rotation methods, which are also valuable, according to Kocher, Ceppi, and Korte, for the reduction. Forcible traction by Simon's "Pendel- methode" or weight-traction often give good results where other methods fail. Violent traction with block and tackle or similar apparatus is abandoned, at least in Germany, on account of the danger of lacerating the skin, vessels, and nerves, and even of tearing the arm out or off. Reduction by operation, or resection, is indicated if the above methods fail. The indication varies according to age, social position, the duration of the dislocation, or an already formed nearthrosis, and is absolute if there are symptoms of pressure upon the nerves or vessels. Subcuta- neous division of the soft parts and adhesions, as employed previously by Dieffenbach and others, and recently recommended by Polaillon and Molliere, finds few advocates at the present time. Whereas at an earlier period, of the two above methods resection alone could be considered, and even until within a few years the majority of surgeons employed arthrotomy only for the rather recent dislocations, the advance in asepsis has prepared a new field, even in old cases, so that the author feels justified in attempting reduction by operation first and resecting later if the necessity is indicated in the course of operation. Schoch, to whom we are indebted for the most recent exposition of the question, advises resection if the head has to be damaged in the operation or if the cavity is too shallow. In the latter case v. Bergmann sutures the anterior portion of the capsule to the biceps tendon to obtain the neces- sary stability. Secondary resection may be required if infection or necrosis of the head results from operation. The statistics of operative reduction given by Schoch show that the failures constitute about 19 per cent, and the successes 65 per cent. The most frequent cause of primary irreducibility was simultaneous fracture; in old cases it w-as hindrance produced by the capsule. The other complications, aside from those produced by the capsule, w T ere fracture of the greater tuber- 76 MALFORMATIONS AND INJURIES OF THE SHOULDER. osity, lesser tuberosity, neck, acromion, or acetabulum, and interposition of the muscles. The incision generally used to expose the head is made along the anterior border of the deltoid, avoiding the circumflex nerve. An axillary incision is occasionally advisable. The subsequent procedure depends upon the condition. In view of the present knowledge of the conditions preventing redaction, it is of great importance in old cases to remove all shrunken and adherent portions of the capsule from the glenoid cavity after the head has been exposed and freed sufficiently to give access to the articular surface. Pronounced shortening of the muscles may necessitate division. On account of the nature of the wound, drainage is advisable. A good result presupposes primary union, early motion, massage, and electricity. If resection is necessary, it should be as limited as possible. Habitual Dislocation of the Shoulder. By relapsing dislocation is understood a recurrence directly following reduction, usually caused by imprudent abduction or paralysis of the muscles. (Arloing.) By habitual dislocation is understood a condition of insufficient stability of the joint allowing dislocation on slight provo- cation. Where the condition is present the dislocation happens fre- quently and often from very slight cause, as in lifting the arm to arrange the hair, in writing, in slipping the arm into a sleeve, in taking out a pocket handkerchief, in mounting a horse, etc. Cases are reported in which the dislocation has occurred 50 or 100 times. Habitual disloca- tion has been seen both of the forward and backward variety; accord- ing to many observers, dislocations backward show the greater tendency to become habitual. The pathogenesis has been studied more carefully since operative treatment has made inspection of the joint possible during life. Jossel has reported the anatomical findings in detail. The capsule is usually abnormally dilated and relaxed. Exceptionally its insertion at the inner margin of the joint is interrupted and the joint communicates with the subscapular bursa. In several instances the rotators or the greater tuberosity were torn off, with the result that the concentric stability of the articular surfaces was lessened during motion. In quite a few of the cases there was a typical groove on the posterior surface of the head to the inner side of the greater tuberosity, regarded by most authors as the result of avulsion, of osteochondritis dissecans, or of trition. Sometimes a small fragment broken off could be demonstrated. On the glenoid surface there are often marked changes; the margin was defective in several instances, usually the inner part corresponding to the greater frequency of subcoracoid dislocations. Burrell and Lovett noted atrophy of certain muscles; in a number of cases they found the coracobrachialis, triceps, deltoid, supraspinatus and infraspinatus, rhomboid, levator anguli scapula?, and latissimus dorsi greatly atrophied and relaxed — in one case one week after the accident. Schrader calls attention to the DISLOGA TIONS OF THE SHOULDER. 77 habitual dislocation developing in syringomyelia, having seen 2 such cases in v. Brims' clinic. It is sometimes of a grade that is never seen in traumatic cases. Treatment. — Bandaging is usually ineffectual. The functional result of operation is not always certain, although recurrence is always pre- vented. The old methods aiming to product' cicatricial contraction of the capsule have been abandoned. The injection of iodoform or tincture of iodine has been successful. Of the non-operative measures, the only ones to be considered are the continued immobilization of the joint for months in a position preventing dislocation or the wearing of protective apparatus, both of which are often unavailing. Weil recommended a padded broad leather girdle binding the shoulder and fitted with an axillary pad. Operation is the proper treatment of habitual dislocation. At first resection was done according to Kilter's instructions, and by the methods of Kramer, Kiister, Volkmann, Lobker, and Kraske; the present opera- tive methods aim to restore the stability of the head by narrowing the relaxed capsule. Ricard uses the purse-string suture and immobilizes for seven weeks. Steinthal reefs the dilated capsule with silkworm-gut without opening it. Most surgeons open the capsule. Gerster, Burrell, and Lovett excise portions of the front of the capsule and suture. Miku- licz divided the capsule longitudinally in one instance, and sutured the inner flap over the outer at the weakest point with four silver-wire sutures. W. Miiller performed 3 such conservative operations, and regards resection as necessary only in extreme cases. He recommends opening the joint, removing any free or pedunculated bodies, resecting the capsule, suturing any torn rotators, and immobilizing for at least fourteen days with tamponage and drainage, in order to obtain the greatest possible retraction of the soft parts; he recommends exposure and suturing in folds in appropriate cases. CHAPTER II. DISEASES OF THE SHOULDER. DISEASES OF THE BURS^J OF THE SHOULDER. Diseases of the bursa? are not always easily differentiated from affections of the joint. The following bursa? will be considered: the acromial, subcoracoid, subscapular, subserrate, and more particularly the subdeltoid and the subacromial frequently communicating with it. Diseases of the Acromial Bursa. — Chronic inflammation and hy- groma result from occupational injuries in people accustomed to carry loads upon the shoulder. A round elastic swelling forms on the shoulder, movable beneath the skin; it is hemispherical, its surface smooth and unlobulated in contrast to lipoma. Such hygromata, as they produce real discomfort and functional disturbance, require excision; the opera- tion is not difficult. Exceptionally, as noted by Vogt, the bursa is enlarged by arthritic deposits; acute suppurative bursitis may supervene upon hygroma after trauma and require incision and drainage. Diseases of the Subdeltoid Bursa,. — The subdeltoid bursa is protected to a certain extent against direct violence by the thick covering of the deltoid, but acute and chronic inflammations are not infrequent, and may present difficulties in the diagnosis. The rare traumatic hygroma is regarded as the result of hematoma. Acute suppurative bursitis has been seen following pneumonia and pyaemia. Jarjavav calls attention to the fact that acute bursitis has been diagnosticated as displacement of the biceps tendon, and explains the error by the involvement of the tendon sheath of the biceps, which produces the functional disturbance of the muscle. Under the name of periarthritis humeroscapularis Duplay describes a chronic adhesive inflammation of the subdeltoid bursa; it results from direct or indirect injury and produces complete obliteration of the sac. In Germany Colley has recently considered this form of disease in a study of 41 cases, mostly in Kuster's clinic, and believes that this process plays a much more important part than was formerly supposed, com- pared to the interarticular changes, in the production of stiff shoulder. He claims that the disease is not infrequent, but is usually mistaken for a joint-affection. The important points in differential diagnosis are the loss of abduction if the scapula is fixed, the existence of mobility in the sagittal plane and of rotation about the long axis, whereas in inflam- mation of the joint all motion is painful; in Duplay's case the scapula followed all movements. In many instances at the onset there is sharp pain radiating down the arm and preventing sleep. Tenderness is limited to the area of the bursa; that part of the joint felt in the axilla is not (78) DISEASES OF THE l'.rilSJE OF THE SHOULDER. 79 Fig. 53. tender. The treatment consists in breaking up the adhesions under anaesthesia; later, massage, passive motion, the faradic current, and baths should be continued until tenderness has disappeared and active motion is free. Rice-body hygroma, a tuberculous bursitis, has been recently described by Blauel in a review of 16 cases following his observation of a typical case in v. Bruns' clinic. The disease is common to all ages except the first ten years and is more frequent in men than in women; it always produces considerable enlargement of the bursa even to the size of half an orange or of a child's head, as in Blauel's and Stanley's cases, and so may be mistaken for a soft sarcoma or, as reported by Ehrhart, for lipoma. The bursa contains characteristic fibrin clots in the form of rice-bodies or "melon seeds" free or pedunculated in clear or turbid serous fluid. The process may advance to the formation of cold abscesses. It is frequently seen accompanying tuberculosis of the joint, as noted by Konig and Ehrhart. The chief symptom is the presence of a hemispherical, tense, fluctuating tumor beneath the deltoid; it is of pro- tracted duration and occasions little discomfort. Crepitus may be obtained from the rubbing together of the rice- bodies; sometimes communication with the joint — as in a case of Hyrtl's — is recognizable from the bulging of the already swollen capsule produced by pressure upon the tumor. This swell- ing of the capsule can be felt in the axilla and obscures the contour of the head. The diagnosis depends chiefly upon the history and the presence of a tumor beneath the deltoid, easily felt if the muscle is contracted. Aspiration gives usually only serosanguineous fluid, or, if the needle is large enough, small rice-bodies; at any rate, it prevents confusion with a neoplasm. The diagnosis is aided by tuberculous lesions elsewhere, as in Blauel's case. The course is chronic. The treatment formerly consisted chiefly in aspirating the fluid con- tents and injecting iodine; later the tumors were opened and the granu- lations scraped out. Total extirpation, as repeatedly employed by v. Bergmann, v. Bruns, and v. Eiselsberg, is the rational procedure. The tumor is exposed by a longitudinal incision over the most prominent point. It is freed at the sides and behind and peeled out in toto; if the sac is very large it may be necessary first to evacuate the contents, or, Hygroma of the subdeltoid bursa. i v. Bruns. 80 DISEASES OF THE SHOULDER. as in Blauel's case, make a long posterior incision; the latter allows free drainage. The so-called "creaking" of the scapula, felt and often heard at a distance during movements of the shoulder-blade, is attributed to the bursa beneath the angle of the scapula, and is met with chiefly in thin subjects, in whom the scapula lies and moves almost immediately upon the ribs. Galvagni has seen the condition many times, especially accompanying pleurisy; once in a case of seamstress' cramp; in another case the fifth and sixth ribs were found denuded and eroded by a large subserrate bursa. Chronic injury may give rise to hygroma ta at places in the shoulder which normally contain no bursa. Wegner describes a bursa the size of a small walnut over the middle of the clavicle, produced by the irritation of the gunstock in the act of "shoulder arms." INFLAMMATORY PROCESSES OF THE AXILLA. Inflammations of the skin of the axilla are frequent by reason of the abundance of sebaceous and sweat-glands. Furuncles are occasionally very protracted and apt to recur. The chronic inflammation of the sweat-glands described by Verneuil as hydradenitis begins as deep- seated firm nodules which gradually soften and suppurate — "sudoripa- rous abscesses." The process is often stubborn, and repeated crops may cause extensive infiltration of the skin. Strong disinfection can only be employed temporarily, as wet bichloride or formalin dressings produce an annoying eczema in the axilla; on the other hand, aluminum acetate is excellent. Abscesses should be incised. The lymph-glands are the structures most affected by inflammatory processes in the axilla. All infections in the upper extremity, the adja- cent thorax, or the breasts, may produce lymphadenitis with or without a recognizable intercurrent lymphangitis. The slight and often unheeded wounds of the fingers are the most frequent contributing causes. Inflam- mation of the lymph-glands is evidenced by the appearance (often rapid) in the axilla of tender nodules of the size of a cherry or hazelnut. In- volution may be equally rapid if the infection at the source is checked early. Spontaneous resolution is aided by rest and the application of iodine or wet dressings. The process may advance to suppuration and periadenitis with adhesion of the skin and to perforation. If the abscesses still contain a large amount of densely infiltrated gland-tissue, persistent fistulas may result. If the abscess perforates into the axillary tissues, extensive phlegmonous abscesses may develop in the axilla and beneath the pectorals with high fever and marked constitutional disturbance; sometimes the inflammation begins in the breast, develops beneath the pectorals, and spreads later to the axilla. Tuberculosis of the axillary glands is not rare, although not so frequent as in the neck, and occurs alone or with tuberculosis elsewhere (cervical glands, shoulder, caries of the ribs, etc.). Occasionally the secondary character of the adenitis may be determined definitelv, as in ANEURISMS IX THE AXILLA. 31 the case of lupus or tuberculosis verrucosa of the hand; in the Tubingen clinic tuberculous adenitis of the axilla was seen in 2 students who had infected their fingers while dissecting a tuberculous cadaver. The char- acter and course of axillary tuberculosis show the same variations as those of cervical adenitis (which see). Gravitation abscesses in tin- axilla, from processes descending along the vessels of the neck or from disease, pyogenic or tuberculous, of the adjacent bones, ribs, clavicle, scapula, or upper end of the humerus or of the shoulder-joint, are much less frequent. Perforating actinomycosis of the lung may also cause an axillary abscess. Treatment. — The treatment of axillary abscesses, except in the case of the tuberculous gravitation abscess, which at the onset is aspirated and injected with iodoform emulsion, is usually free incision. Based upon the favorable experience of several years, tlie author always follows the incision with the application of concentrated carbolic acid, as used by Phelps, providing that the cavities are not in contact with the large vessels. For fistulous suppuration of the glands the author prefers removal of the glandular remnants as the safest and quickest method, although it cannot be denied that patience, the spoon, and silver nitrate may finally effect recovery. Large masses of tuberculous glands are indication for the typical cleaning out of the axilla. (See Vol. II., page 60S.) Thick indurated masses extending higher, to be removed thoroughly, may necessitate division of the pectorali-. ANEURISMS IN THE AXILLA. Aneurism of the axillary artery results either from atheroma or other diseases of the vessels or from injury (which see). Of 69 cases of aneurism of the axillary artery collected by Koch, 32 occurred spon- taneously or without special cause, 12 from a fall, a blow, and over- exertion; 1 from fracture, 4 in reducing dislocations, and 9 each from puncture and gunshot-wounds. The traumatic cause may often be very slight; Bardeleben saw an aneurism produced by the pressure of a crutch. The mode of origin of traumatic aneurisms varies according to the nature of the injury: a wide opening in the vessel may allow of diffuse extravasation, from which the aneurism may be formed by the gradual cicatricial thickening of the adjacent tissues, or the wound may first close and the aneurism be formed later by the stretching of the cicatrix, as produced exceptionally by sudden increase in blood-pressure; also in partial lesions of the coverings by ectasis of the intact adven- titia. Spontaneous aneurism of the axillary artery is most frequent between the fortieth and fiftieth years, and is more common in men than in women. Of 591 aneurisms, of which 308 were superficial and accessible, Crisp found 18 in the axilla. Symptoms. — The chief symptom of axillary aneurism is the gradual development of an ovoid, round, or spindle-shaped tumor, either beneath the clavicle in the triangle between the clavicle and edge of the pectoralis, Vol. III.— 32 DISEASES OF THE SHO ULDER. beneath the pectoralis at its lower margin, or in the axilla, accord- ing as the growth affects the first or last portion of the artery. The pulsation, isochronous with the heart-systole, and the blowing murmur heard over the aneurism are characteristic; on compressing the sul>- clavian artery these symptoms disappear. The tumor is usually soft and compressible; this quality may be absent if there is a moderate deposit of fibrin in the sac. Large aneurisms may press upon the plexus and produce numbness in the fingers and arm, radiating pains, and finally oedema and coldness from obstruction of the veins. Very large tumors may produce gangrene. From the above symptoms the diagnosis is not difficult. The possibility of mistaking aneurism for an abscess is known and dreaded, but is dangerous only if the aneurism is treated as such. A pulsating sarcoma may also be confused with aneurism. The course is usually progressive: as a rule the aneurism extends downward and forward, rarely upward, so that the clavicle is pushed upward and dislocated at its sternal end, and the first and second ribs eroded. Generally a spontaneous aneurism increases more slowly and to lesser proportions than the traumatic variety. If far advanced, the chief danger lies in the increasing attenuation of the coverings and rupture with or without inflammation. Treatment. — The treatment is essentially operative. Rest, applica- tion of ice, and compression of the subclavian by intermittent digital pressure may be tried, but are usually not well borne. In the majority of instances the best method is ligation of the artery above and below the aneurism and evacuation or extirpation of the sac. Inflamma- tory adhesion with the surrounding structures may make the operation a delicate one; the greatest difficulty is met with in the diffuse extrava- sation of the early stage of traumatic aneurism in the infraclavicular space. (See page 22.) Hunter's method of simple ligation of the subclavian has not given good results in the case of axillary aneurisms. (See Popliteal Aneurisms.) Several instances of arteriovenous aneurism of the subclavian beneath the clavicle and of the axillary have been seen, most frequently following gunshot-wounds, v. Bramann knows of 6 cases in which the subclavian was affected, usually beneath the clavicle, and 5 of the axillary. As a rule, the communication is between the main trunks of the artery and vein, in one case between the axillary artery and basilar vein. For the development, anatomy, and symptoms, see Vol. II., page 66 ff. The functional disturbances are usually marked, the venous con- gestion producing enormous swelling — even 3 inches' difference in cir- cumference of the arm — subnormal temperature of even 4° to 8° C, and a feeling of heaviness and muscular weakness in the arm fre- quently resulting in complete disability. Simultaneous injury or com- pression of the nerves may increase the disturbance. For these condi- tions active treatment is indicated. Up to the present time only double ligation of both vessels, and if possible extirpation of the sac, have been beneficial; by this method v. Bergmann obtained an uninterrupted NEOPLASMS OF Till-: AXILLA. 83 recovery in a case of axillary arteriovenous aneurism, and recently Erdmann similarly in a case of the subclavian aneurism from a gunshot- wound in Mohrenheim's space. According to v. Bramann's statistics, compression and Hunter's proximal ligation have given poor results. How far the modern achievement of vascular suture is applicable to aneurism of the axillary remains to be seen. (See Popliteal Aneurism-. NEOPLASMS OF THE AXILLA. The benign neoplasms of the axilla are lipoma, fibroma, and angioma. Lipoma, either with a broad base or pedunculated, is not infrequent and often attains considerable size. Burow saw a twenty-eight-pound lipoma of the axilla. Extirpation is usually not difficult; attention must be paid to the larger of the veins entering the tumor. Angioma occurs in the form of various nsevoid tumors, either congenital or as a mixed tumor combined with lipoma. The cavernous angioma is of more practical importance. It is distinguishable from aneurism by the swell- ing produced by coughing and pressure, the absence of pulsation, the livid color, the dilated branches of the vessels, often plainly visible beneath the skin; also the compressibility and mobility of the tumor upon the deeper structures, and the fact that compression of the subclavian produces no effect. If excision is counterindicated by the diffuseness of the tumor, thermopuncture and electropuncture are in order; and where it extends deeply and widely, the injection of alcohol. Lymphangioma, cavernous or cystic, develops, analogous to cystic hygroma of the neck, chiefly in childhood and preferably along the lymphatics in the axilla and upward beneath the pectoralis toward the clavicle. The tumor may be very large and constricted by the pectoralis as by a purse-string. A hematoma is always suggestive of hemorrhage from the walls and septa of a previously cystic lymphan- gioma; the etiology can be cleared up only by a microscopical examina- tion. Among the benign tumors of the axilla should be classified the cases of aberrant mamma. (Compare Vol. II., page 562.) Malignant tumors of the axilla usually start from the lymph-glands, and are then generally secondary; we are justified to-day in regarding as doubtful the cases of primary carcinoma of the lymph-glands occa- sionally reported. Primary sarcoma may arise in the lymph-glands, the vessels, the skin; also as a malignant neuroma it is often seen attached to the branches of the nerves. Primary carcinoma of the skin is rare; exceptionally a cicatrix, papilloma, or lupus can be demonstrated as the point of origin; secondary involvement of the axillary glands is most frequently from carcinoma of the breast. The large tumors pro- duced in the axilla by Billroth's malignant lymphoma have already been mentioned. (See Vol. II., page 110.) For the technic of excision of malignant tumors of the axilla, see Carcinoma of the Breast, Vol. II.) Interscapulothoracic amputation 84 DISEASES OF THE SHOULDER. should be considered when the tumor involves the shoulder-joint or the vessels and nerves, unless operation is counterindicated by the general condition or metastases. NEOPLASMS IN THE SOFT PARTS OF THE SHOULDER. All sorts of neoplasms occur in the shoulder: angioma, nsevus, fibroma, keloid after burns, sarcoma, and carcinoma. The shoulder is the most frequent site of lipoma, which often grows to an enormous size and develops into a more or less pendulous tumor. Such a tumor, growing slowly and without pain, tense, elastic, and often giving pseudofluctua- tion, is easily recognized by its lobulated surface and can be confused only with hygroma at or near the acromion. Rarely it produces sub- jective disturbances independent of its size; lameness, increasing in the course of years with the growth of the tumor, as noted by Vogt; occa- sionally atrophy of the muscles of the thumb, evident at an early period; also slight weakness of the hand and varying sensory disturbances. Single lobes of the tumor may invade the fascia between the muscles, or the tumor may begin in the subfascial tissues and gradually push its way upward. Lipoma is usually excised without difficulty. The inci- sion should be made so as to produce the least possible disturbance; the tumor is removed by blunt dissection; areas partly or entirely excoriated on the highest portion of the tumor are to be removed. A peculiar formation of the skin and subcutaneous tissue resembling elephantiasis is described by Mott and Danzel as pachydermatocele, brownish pigmented growths of skin, depending in folds like a collar over the clavicle and shoulder. It is a hypertrophic condition of the skin and subcutaneous tissue. Carcinoma of the shoulder is rare; Schreiber saw such in the case of a pack-carrier, the growth extending to the periosteum and eroding the spine of the scapula. It started from a hygroma over the spine of the scapula. Tumors of the deltoid are rare and are chiefly sarcomata, as noted by Vallas, Nove, and Delbet. The prognosis is usually unfavorable. Recurrence is generally rapid so that extirpation of the tumor, recurrent operation, exarticulation, and total amputation of the shoulder follow each other rapidly, as in a case reported by Heddaus in Czerny's clinic; Schuh records a neuroma of the size of a bean excised from the substance of the deltoid, that had produced unbearable pain. Recently Honsell in v. Bruns' clinic described an enchondroma of the size of two fists that in two weeks had grown to these proportions within the deltoid without producing any particular discomfort. The so-called " exercise-bone" — in hunters, '"shooting-bone" — result- ing from repeated injury while exercising and turning, particularly in the case of recruits, is a form of ossification occurring in the deltoid or cora- cobrachialis; it is probably an ossification of the connective tissue which is left after intramuscular hemorrhages. This purely local bone forma- tion gives a good prognosis in contrast to progressive ossifying myositis. DISK ISKS OK TIIK CI. A VICLE. 85 DISEASES OF THE CLAVICLE. In the clavicle acute periostitis and ostitis are rare; genuine infec- tious osteomyelitis is equally uncommon in the clavicle, Inn may produce extensive or total necrosis. Frohner's statistics from v. Bruns s clinic give 3 I cases of acute osteomyelitis of the short and flat hones in contrast to 170 of the long bones; the clavicle was affected in 8 cases. In 2 instances of total necrosis of the clavicle there was subsequently complete regeneration, the form of the hone and the function of the arm being preserved. Tuberculosis of the shaft of the clavicle is rare in contrast to the frequency of osteal foci observed in the sternal end. Syphilis, both hereditary and acquired, often becomes local- ized in the clavicle, especially in the sternal end, in the form of gummatous protrusions — the so-called tophi — which may sub- sequently soften and suppurate. If the growth is rapid, it may be mistaken for sarcoma. If spe- cific treatment does not bring about healing of the fistulse and sequestra, recovery is often ef- fected rapidly with the aid of the knife and sharp spoon. Enu- cleation or partial or total resec- tion are indicated in tubercu- losis of the clavicle, according to the amount of destruction present. The joints of the clavicle are seldom diseased. Subluxation occasionally takes place as the result of diseases which cause forced breathing; also as the result of ankylosis of the shoulder, as noted by Albert, in conse- quence of the greater movements required of the sternoclavicular joint; further from the pressure of subclavicular tumors — aneurism of the innominate, as reported by Holland. Inflammatory diseases affect the acromial joint less frequently than the sternal; fibrous, fungous, and deforming- arthritis, occasionally with a pathological downward subluxa- tion of the scapula, have been reported. Tuberculous caries of the sternoclavicular joint is not rare; thorough scraping usually checks the process; if not, resection is indicated. This joint may be also involved in gummatous processes; occasionally the affection is bilateral. If the Fig. 54. % ■ ■ 1 i& 1 ^Ukttf Sarcoma of the clavicle. 86 DISEASES OF THE SHOULDER. focus has perforated outward, scraping may be necessary in addition to potassium iodide internally. According to Gurlt, chronic diseases of the clavicular joints frequently accompany those of the shoulder-joint. Neuropathic arthritis of the sternoclavicular joint is often reported in connection with syringomyelia. Neoplasms are rare in the clavicle. Osteoma and chondroma arc most frequently seen following injury. Osteosarcoma and myeloid sarcoma have been reported repeatedly; Courtin saw an instance of rapidly growing osteosarcoma neonatorum. Resection or total excision is indicated according to the size and nature of the tumor (for the technic, see later). The functional result is favorable even after total excision by which the periosteum is removed and regeneration made impossible. In the majority of instances motion of the arm is entirely free and any depression of the shoulder scarcely noticeable. Norkus in 1894 collected 74 cases of total excision of the clavicle; 31 were for necrosis and caries, 33 for malignant tumors, and 3 for gunshot-wounds. DISEASES OF THE SCAPULA. Acute periostitis and osteomyelitis are also rare in the scapula; post- traumatic disease affects more commonly the prominent portions of the bone, the spine, and coracoid process. The most frequent disease of the bone is tuberculosis, either in the form of typical granulating foci perforating into the joint, large caseous foci in the body or spine, or tuberculous sequestra, as noted by Cousin. The course is usually protracted; the abscesses may reach the surface by a circuitous route; the suppuration may be very exhausting. Disease of the spine and the lower portion of the scapula will demand resection more frequently than foci about the joint; in the latter case, if the joint is not involved, the operation is limited to removing the granulating foci or sequestra. For such partial resections Kocher advises entrance from behind through an incision carried from the acromioclavicular joint over the shoulder, along the spine of the scapula to about its middle, and then in a curve downward to the posterior fold of the axilla. Rarely total resection will be indicated for extensive caries or necrosis; such instances are occasion- ally reported. Mikulicz and Hashimoto have shown of what complete regeneration the scapula is capable after subperiosteal resection. Tumors of the scapula are not particularly rare, and are seen more frequently in children than in adults. The benign tumors are exostoses, osteoma, fibroma, cartilaginous exostoses, and simple enchondroma; the more frequent malignant tumors are colloid and cystic chondroma, chondrosarcoma, sarcoma, and carcinoma. Among 72 cases of scapular tumors Langenhagen records 8 of exostosis, 14 of chondroma, 5 of fibroma, 23 of carcinoma, 12 of sarcoma, and 2 undetermined. Walder reports 19 cases of enchondroma, 30 of carcinoma, and 16 of sarcoma. Myxochondroma and cystochondroma, sarcoma and osteoid sarcoma are characterized by their rapid growth and tendency to metastasis. The DISEASES OF THE SCAPULA. 87 soft sarcomata are very apt to invade the muscles. In the majority of cases the tumor arises iii the body of the scapula; less frequently in the processes, the spine, or the angle. It usually advances toward the infra- spinate or supraspinate fossa; souk times it grows more toward the anterior surface and appears first near the axilla, as noted by Ilclferich. As soon as the tumor becomes very large it not only pushes the shoulder forward, hut also presses the arm downward, possibly causing disloca- tion, as noted by Bellamy. It may grow forward. Especially ,I(i - r, - r >- cystochondroma and myxochon- droma, chondrosarcoma, sar- coma, and osteoid sarcoma grow to enormous proportions, weigh- ing even 30 pounds, as in a case reported by v. Eiselsberg. In- volvement of the glands is not constant even in the case of ex- tensive tumors. Walder collected 25 cases of chondroma of the scapula from the literature; 11 were colloid, the rest were cysto- chondroma. These tumors ap- pear generally about the fortieth year, while the pure enchondro- mata are more frequent in youth, and grow in one and a half years to the size of a fist or a child's head. In not a few of the cases trauma, such as a blow, a fall upon the shoulder, etc., is given as the cause; in several instances the beginning tumor was mistaken for a ruptured muscle. The cases are more frequent in which the already existent tumor, previously manifesting a slow growth, was suddenly stimulated to rapid growth by the trauma. The symptoms at the outset are slight, vague, dull pain and trifling impairment of motion, so that the disease is sometimes regarded as rheumatism, as noted by Sendler. If the tumor increases slowly toward the subscapular fossa, it may be mistaken for an inflammatory affection, particularly if it is deep seated, thickly covered by the soft parts, or gives pseudofluctuation. This is especially the case if its development is accompanied by fever. Often the changed configuration and the dis- tended veins of the shoulder will arouse suspicion before any considerable functional disturbance has developed. The diagnosis, so simple in the Sarcoma of the scapula. 88 DISEASES OF THE SHOULDER. Fig case of large tumors, is equally difficult sometimes at the onset, vet it is very important that it should be made as early as possible. In doubtful cases aspiration may give evidence of a fluctuating swelling. The prognosis of malignant neoplasms is unfavorable; particularly the soft, rapidly growing forms advance to general dissemination, to metas- tases in the inner organs, especially in the lungs and pleura, and in the vertebra?, as noted by Southam. The treatment consists in the earliest possible radical removal of the tumor and in the majority of cases, if shoulder-joint and arm are still intact, tins means total excision of the scapula. Partial resection is justifiable only for benign tumors like exostoses or for secondary tumors of the bones arising from the soft parts. In 32 cases of total excision of the scapula with preservation of the arm, Doll gives 8 deaths soon after the operation, 12 recurrences, and 12 recoveries. In the cases of scapular tumors operated upon subsequent to 1S75, Schultz gives 7 per cent, mortality, 18 per cent, recurrence, 64 per cent, of recovery, of which 11 per cent, was verified later as permanent. In many cases it seems advis- able also to remove part of the head of the humerus or a larger portion of the clavicle. If the neoplasm involves the deltoid or the arm, but is otherwise still oper- able, interscapulothoracic ampu- tation is indicated. The removal of the entire shoulder for malig- nant tumors subsequent to 1875, the year of the introduction of antisepsis, resulted in 13 per cent, mortality from operation, 28 per cent, mortality from recurrence and metastases, 57 per cent, of recoveries — 2o per cent, being verified later as permanent — in 3 percent, the result was unknown. From the statistics available at the present time — Adel- mann, Schwartz, Gies, Rogers, and Schultz — it is unquestionable that the earlier the operation the better the chances of recovery; and further, although the surgeon too often sees rapid recurrence following his best efforts, it must be remembered that a second operation may still be successful- The result represented by 17 percent, of definite recoveries can still be improved upon. Sarcoma of the scapula same a- Fi-;. 55 . >> (D ■•-> s- < >> < INFLAMMATORY DISEASES OF THE SHOULDER JOINT, gy INFLAMMATORY DISEASES OF THE SHOULDER-JOINT. Inflammatory diseases of the shoulder-joint are seen in the most diverse forms, both acute and chronic, severe or mild, arising from the synovialis or from the bones, especially the head of the humerus, and with or without effusion. The effusion may be serous, sanguineous, sero- fibrinous, seropurulent, or purulent. The disease may occur alone or be a local manifestation of a general disease. On account of the thick muscular covering and deep situation of the joint the changes in form are rarely marked. They are noticeable only when from atrophy of the muscles and relaxation of the ligaments the head of the humerus sinks away from the glenoid cavity, or when Fig. 57. pathological partial or complete dislocation is produced by fur- ther changes in the structures of the joint. The symptoms at the onset are chiefly impairment of motion, especially of abduction, and pain. It is only in certain forms that we find effusion with bulging at the bicipital groove or beneath the coracoid process or in the axilla. In regard to the diagnosis, it must be remembered that many affections of the bursas of the shoulder may resemble dis- eases of the joint: and further, they are not infrequently com- bined. In testing the mobility one should always notice whether the apparent movement at the joint is not transmitted from the scapula. Serous and Fibrous Omarthri- tis. — The tWO forms are not Sarcoma of the scapula (same as Fig. 55). easily distinguished from each other, as the resorption of the primary inflammatory effusion is often followed by a growth of vascular connective tissue over the articular surfaces and by inflammatory adhesions in the recesses of the joint. Acute serous effusion in the joint is observed chiefly after injury, such as a sprain or contusion. Rarely the capsule is so distended that the humerus is slightly abducted and rotated inward. The bulging of the capsule is usually too slight to be noticeable. Fluctuating prom- inences at the points related above occur only when the effusion is very marked. The swelling may be more uniform if the periarticular tissue is involved in the infiltration; otherwise swelling in the region of the deltoid should always suggest involvement of the subdeltoid bursa. 90 DISEASES OF THE SHO ULDER. Marked dorsal swelling and bulging beneath the acromion signify dis- tention of the subacromial and subdeltoid bursse. By pressing upon the joint the bulging of the capsule beneath the thin covering of the sub- scapularis in the axilla is easily recognized; also the abnormal mobility of the head, as the condition is somewhat of the nature of a loose joint. Exceptionally the distention of the capsule is such as to produce a distention dislocation, as noted by Malgaigne. This form of inflammation is not infrequently a local manifestation of an infectious disease, as, for example, acute and chronic rheumatism; in pyaemia and sepsis the involvement of the joint may take the form of a pure serous or fibrinous inflammation. Whereas acute rheumatic omarthritis belongs to the physician, the chronic form, by reason of the necessary prophylaxis of the threatening stiffness, becomes the thankless task of the surgeon. In the advanced stages of chronic rheumatism there are more marked tissue-changes, thickening of the capsule, villous growths, forming the transition to the picture of hyperplastic inflam- mation. In the severest form there are adhesions between the fibrin- covered joint-surfaces, and finally fibrous or bony anchylosis. Symptoms. — The symptoms of serofibrinous and fibrinous omarthritis are chiefly functional: impairment of the movements of the arm, espe- cially abduction, and pain on passive motion, especially rotation; later, the loosening of the ligaments and the action of gravity produce a slight lowering of the arm so that the acromion becomes more prominent and a depression can be seen and felt between it and the head of the humerus. Villous growths give rise to more or less fine crepitus. Treatment. — The treatment consists in immobilization, the ice-bag for severe pain, and if rheumatism is suspected, 45 to 65 grains of sodium salicylate internally daily. If the effusion does not yield to careful massage, inunction, or iodine locally, subcutaneous irrigation of the joint with 3 per cent, carbolic acid or 1 : 5000 bichloride solution is indicated. In all cases of irritation of the joint following sprain or contusion with or without htemarthrosis, and characterized by deficient mobility of the shoulder-joint, etc., the patient should not be left to his own resources, as he is content to carry the arm in a sling and will surely obtain a stiff joint if not obliged to work. Compare the remarks on page 46. The many forms of balneotherapy used in chronic rheumatism cannot be discussed here. A series of methods depending essentially upon the production of hyperaemia belong more to surgery, however; among these the hot-air baths (110° C), as recommended by Krause and Bier, for several hours daily. Bier commends even more the effect of passive congestion, which' the author has also found valuable. Particularly striking is its favorable action upon the pain and stiffness. It cannot be denied, however, that its application here is more difficult and less agreeable than at the more peripheral joints. Bier recommends that a cloth sling be placed around the neck loosely, the ends being passed around the other shoulder in the form of a spica and tied in the axilla. A well-padded rubber tube is applied about the affected shoulder, the ends drawn sufficiently tight through the neckband and fastened with a clamp; INFLAMMATORY DISEASES OF THE SHOULDER JOINT. 91 the aeckband prevents the tube from slipping off; the hand and arm are bandaged snugly; the rubber tube may be left on (under observation) for twelve hours. The results obtained up to the present time by opera- tion in chronic rheumatism of the joint — arthrotomy, resection, etc. — do not justify the indication of such operations. Purulent Omarthritis. Purulent inflammations of the joint may be acute or chronic. The severesl forms of acute suppuration follow injury, such as compound splinter-fractures, gunshot-fractures of the joint; are transmitted from an acute osteomyelitis, or occur during the infectious diseases (smallpox, pyaemia, typhus, scarlet, or puerperal fever). Symptoms. — Acute purulent inflammation of the joint begins with intense pain, high fever, marked swelling, and severe functional disturb- ance. The skin rapidly becomes hot and red, and if treatment is not energetic or the patient becomes pyaemic or septic, the capsule becomes perforated and the abscess appears in front beneath the deltoid, along the biceps or at the lower edge of the subseapularis. The cartilage is rapidly destroyed by the suppuration, so that during passive motion, which is very painful, fine, bony crepitus can be felt. If perforation outward is delayed, the periarticular abscesses may burrow extensively, and lead finally to the formation of numerous fistulas about the scapula, on the thorax, and on the arm. Prognosis. — The prognosis varies greatly with the severity of the affection, and in general and with reference to the function is unfavor- able. In pyaemic and metastatic suppuration of the joint the general infection almost always makes the prognosis unfavorable, whereas single metastases are relatively benign. Treatment. — "Ubi pus, ibi evacuo," applies to suppuration of the shoulder-joint. In the milder forms (the so-called catarrhal suppuration) irrigation with 3 per cent, carbolic acid or 1 : 1000 bichloride solution is justifiable. Schede obtained good results in this way; before injecting, the pus should be aspirated through the needle and sterilized salt solution injected and aspirated on account of the coagulative action of the above chemicals. If the irrigation is not effectual or appears a priori to offer no relief, as, for example, in the phlegmonous form, free drainage should be obtained by arthrotomy, preferably behind and below; and if this fails, resection is indicated. Further, extensive disease of the soft parts of the upper arm may necessitate amputation at the shoulder. If antiseptic treatment is begun early, recovery with good function is not impossible. As a rule, however, suppuration of the joint is followed by more or less complete ankylosis. Even in this case much depends upon appropriate after-treatment. If recovery with ankylosis is probable, the joint should be fixed in slight abduction. Gonorrhoea and syphilis should be mentioned particularly as special etiological factors liable to produce serous and purulent inflammation of the joint. Gonorrhoeal arthritis, first properly estimated in the recent works of Xasse, Bennecke, and others, most frequently attacks the knee-joint — 46 per cent. It also affects the shoulder-joint alone or with other joints; 92 DISEASES OF THE SHO ULDER. the inflammation is more often serofibrinous than purulent, and the latter form does not usually produce as much destruction of the tissues as the phlegmonous suppuration; it has more the character of the catarrhal suppuration. Benneeke saw 4 cases, 2 severe and 2 mild; Sehreiber his repeatedly seen serofibrinous gonorrheal omarthritis. The metastases in the joint may develop at any stage of the gonor- rhoea; the onset is always acnte. The symptoms are comparable to those of acute serofibrinous omarthritis. The differential diagnosis depends upon the evidence of a present or past gonorrhoea. In the severer cases the course is more protracted. The prognosis is doubt- ful as to the restoration of mobility. In the treatment the same measures are applicable as in the case of rheumatic inflammations. Bier has seen particularly good results from passive congestion. Operation may be necessary. In one instance Konig split the sheath of the biceps tendon down to the joint, irrigated with 3 per cent, car- bolic acid, and in one year obtained almost free motion. Schuchardt recommends injection of a 1 per cent, solution of protargol. Syphilitic omarthritis may occur during the second stage and is usually serous; commonly other joints — the knee — are also involved; in the tertiary stage there may be a gummatous synovitis with softening and suppuration in the joint. Gummatous foci in the head of the humerus may involve the joint. By the formation of fibrous thickening, cir- cumscribed hyperostoses, and irregular defects in the cartilage, the joint may be so deformed that subluxation takes place. The head may be greatly destroyed by gummatous rarefaction. The treatment is specific, potassium iodide in large doses. Operation is rarely indicated. Tuberculous Omarthritis. — The shoulder-joint, in comparison with other joints, is rarely affected by tuberculosis. According to Billroth, caries of the shoulder-joint represents 2 per cent, of the cases. Konig saw 60 cases, in 38 of which the right side was affected, in 22 the left; in 25 per cent, the primary disease was synovial, in 75 per cent, osteal. Gangolph reports 29 of 32 cases as primarily osteal. According to Mondan and Audry, 90 of every 100 cases of chronic arthritis are tuber- culous. The disease is most common in the fourteenth to the thirtieth year. Trauma is not infrequently regarded as the cause. Pathological Anatomy. — The pathologico-anatomical changes vary greatly according to the extent of the disease. Exceptionally one sees changes in the form of circumscribed nodules arising in the free parts of the capsule and growing into its substance. In the majority of cases the primary synovial form is diffuse, the membrane being filled with numerous gray or yellow-gray nodules; or the entire membrane is thickened and infiltrated, presenting the so-called fungous swelling (omarthritis fungosa); or there is a cloudy serous effusion or puru- lent fluid in the joint containing a greater or lesser quantity of fibrin. The controversy in regard to the origin of the fibrin cannot be entered into here. Fibrinous hydrops is rare in this joint. The grayish-red, soft granulations, which protrude on cutting into such a joint, invade the cartilage and gradually destroy it, producing the picture of caries INFLAMMATORY DISEASES OF Til/: siinrLhEll JOIST. 93 of the shoulder. The primary foci of the osteal form may be in the head of the humerus or in the glenoid portion; occasionally one finds large cheesy foci and characteristic wedge-shaped infarcts or tuberculous Fig. 58. Fig. 59. Tuberculous sequesti end of the femur. 11 in the upper iv. Bruns.) sequestra, in children lying chiefly near the epiphyseal line, sometimes centrally in a bony cavity. (Fig. 58.) The most frequent form of tuberculosis of the shoulder- joint is the so-called caries sicca, in which there is a for- mation of thin, slightly vascu- lar granulation-tissue, which gradually destroys the head. In the beginning there is a formation of sinuous furrows or deep cavities, chiefly along the border of the anatomical neck; in the advanced stages there is often little left of the head, and the disease may even attack the shaft, in which case, in younger subjects, there may be marked changes in the length and thickness of the bone. Caries sicca, as generally described, proceeds without suppuration and is usually accompanied by shrinkage of the capsule, so that the diminishing head is drawn into the glenoid cavity or against the coracoid process. (Fig. 59.) There are cases, however, in which the entire picture is that of Caries sicca of the right shoulder-joint (front view). The head of the humerus (a) is practi- cally lacking, the remaining portion being united so firmly to the almost unaltered glenoid cavity (b) by tense granulation-tissue that during life motion was entirely cheeked, and the condition resembled a subcoracoid dislocation. c. Cora- coid process, d. Acromion, e. Body of the scap- ula sawed off. /. Shaft of humerus. (After Krause.) 94 DISEASES OF THE SHO ULDER. caries sicca, but in which fistulas are formed. In the light of our pres- ent knowledge of the etiology of caries sicca these transition and com- bination forms seem quite natural. Mondan and Audry saw 27 cases with suppuration in 33 of tuberculosis of the joint. In the author's experience suppuration is a fairly frequent occurrence in tuberculosis of the shoulder-joint. The author has already mentioned the in- volvement of the periarticular bursa?. There is a rare form called caries carnosa, in which the spongy bone is replaced by soft sar- coid masses filled with tubercles, and which may extend into the medulla. While there is nothing particularly characteristic in the clinical course of fungous omarthritis compared with the other forms of joint tuber- culosis, the picture of caries sicca of the shoulder-joint is typical. In the beginning there is a feeling of weakness and stiffness, especially in the morning on arising, soon followed by more or less active attacks of neuralgic pain; local tenderness is particularly marked in the axilla and at the greater tuberosity and is unaccompanied by marked swelling. But at an early period there is a striking flattening of the shoulder, depending partly upon the atrophy of the deltoid, partly upon the atrophy of the head. This results in the sharp projection of the acromion, the same being increased occasionally by inward and downward dis- placement of the head. In youthful subjects the growth of the head of the humerus is retarded. These cases are often mistaken, especially in the beginning, for joint neuroses; for rheumatism, if there is an irregular febrile movement; if developing after injury, for a traumatic inflammation of the joint; so that Konig says, rightly, "There is scarcely a joint concerning which so many sins of diagnosis are still committed at the present time with reference to tuberculosis as the shoulder-joint." Incipient tumors of the head of the humerus may be mistaken for tuberculosis of the joint; in the former case the swelling is absent in the joint and present more at the epiphysis. Prognosis. — If the process is localized, the prognosis as to life is not unfavorable; unfortunately, however, the disease in the shoulder is fre- quently accompanied by tuberculosis of the organs, especially the lungs. The prognosis of the local affection varies with the extent of the process; extensive fistulas and suppuration are less favorable on account of the danger of cachexia. Caries sicca usually heals in one to two years with fibrous ankylosis; nevertheless Konig, in resecting a case of ten years' duration, found fairly recent foci. Osteal foci give the best prognosis, as they perforate without involving the joint and can be opened without arthrotomy. In young subjects considerable disturbance in growth often persists in spite of favorable recovery. Treatment. — At the onset the treatment consists solely in immobili- zation and injection of iodoform. By passive congestion Bier also obtained good results in caries sicca. It is not advisable to try to mobilize a stiff joint. Resection is indicated for the cases in which in spite of conservative treatment pain and functional disturbance persist INFLA MM A TOR Y DISEASES OF THE SHO ULDER-JOIST. 95 Fig. 60. and suppuration and fistulas appear; by removing the head and all tuberculous tissue in the capsule and glenoid portion of the joint, more favorable conditions for functional recovery arc established. Although it cannot be denied that death from tuberculosis follows the operation rapidly in individual cases, nevertheless most of the patients arc bene- fited by resection even if pulmonary tuberculosis occurs, as the pain is mitigated and the arm and hand made more useful. In children, how- ever, resection may be unnecessary, as foci — tuberculous sequestra are often operable without removing the head. Very extensive and malig- nant tuberculosis of the shoulder — caries carnosa of Konig — may demand amputation of the humerus. Omarthritis Deformans. — Arthritis deformans is most common in advanced age and affects more particularly laborers who do hard work in the open air; it is not infrequent in the shoulder-joint. It is well known that severe injuries — fractures of the joint, dislocation, sprain — may be the cause of this deforming inflammation in addition to the slight mechanical and atmospheric influences, to which the joints of laborers are usually exposed. If everything classified in the present accident insurance practice under the name of traumatic arthritis defor- mans should be accepted scientifically, the etiological significance of trauma would be overestimated. Many a case has to be admitted by the court as traumatic because at the time of the decision it could not be determined what the condition of the joint was before the accident. In other instances careful ex- amination of the other uninjured shoulder- joint demonstrates that here also the de- forming process is already well advanced. Pathological Anatomy. — The hyperplastic and regressive changes of cartilage and bone occurring in arthritis deformans are mani- fold. The synovialis may be covered with villi and tuberous growths, the capsule thick- ened, the head of the humerus enlarged and with growths along the margin, its convexity flattened and worn smooth in places. (Fig. 60.) The growths along the margin may pro- ject like fungi or in part become free-bodies. The glenoid cavity is usually circular, at times irregular, broadened, and displaced toward the subscapular surface. There may be a sort of partial dislocation, the joint-surface being divided to a certain extent into halves, the dividing ridge corresponding to the inner border of the joint. Ex- ceptionally the head is dislocated more toward the infraspinate fossa; on the other hand, it is frequently drawn close against the acromion by the shortening of the capsule and the tendon of the supraspinatus. The biceps tendon may be entirely frayed out and rupture spontane- \ 96 DISEASES OF THE SHO ULDER. ously. The amount of serous effusion varies considerably. There is never true ankylosis. Symptoms. — The symptoms at the onset are slight pain and impair- ment of individual movements, especially abduction and rotation. Soon a peculiar crepitation is noticed during more active movements, which may be evident to the patient and heard at some distance. The swelling of the capsule, the effusion, and the enlargement of the head become more and more noticeable as the increasing muscular atrophy hinders motion. In advanced cases the diagnosis is seldom difficult. In the early stages the differentiation from chronic rheumatism may be difficult, especially as more confusion reigns in the literature on these two diseases than on almost any other one subject. Prognosis. — The prognosis is unfavorable; in the majority of cases the process advances steadily and remissions are rare. Treatment. — The treatment at the onset consists in massage, gymnastic exercises, a course at some bath — Teplitz, Wildbad, Wiesbaden, Gas- tein, Ragatz — or mud-baths; also the various methods of producing hyperemia — active inunctions, hot air, passive congestion, etc. — may now and then exert a favorable influence. For profuse effusions irriga- tion with carbolic acid solution is indicated; finally protective apparatus may be necessary. Atrophy of the muscles should be combated by elec- tricity. Resection may be demanded for severe monarticular disease in young patients. Neuropathic Omarthritis. — Neuropathic arthritis of the shoulder occurs in the course of various diseases of the central nervous system, chiefly in syringomyelia, rarely in tabes. The arthropathy of syringo- myelia affects more particularly the upper extremity — in about 80 per cent, of the cases — especially the shoulder-joint, whereas in tabes the joints of the lower extremity are more often affected — 76 to SO per cent. Not infrequently several joints are involved at the same time. In spite of the relatively short time during which the disease has been recognized in the literature, 50 cases of shoulder involvement in syringomyelia are already known, whereas, from the recent statistics of Rotter, Sonnen- burg, Kredel, and Weizsaecker, only about 36 cases from tabes are reported, a small number in comparison to the enormous frequency of tabes. In 17 cases of syringomyelia in v. Brims' clinic there were 20 arthropathies, 12 of the shoulder. Schlesinger estimates the frequency of arthropathy in syringomyelia at about 20 to 25 percent. Sometimes trauma provokes a rapid development of the joint-affection; in other cases it merely reveals the disease. Pathological Anatomy. — The anatomical picture is extraordinarily characteristic. Qualitatively the changes are those of arthritis defor- mans, but quantitatively there is a great difference, in that the effect of the degenerative processes borders on the grotesque. The degree of growth and destruction of the bone reached is never seen in arthritis deformans. The osteophyte formation extends to the shaft; even the adjoining muscles may be ossified. In the hypertrophic form the processes of growth, producing thickening of the articular surfaces, INFLAMMATORY DISEASES OF THE SHOULDER-JOINT. 97 osteophytes, marginal masses, and villi, predominate. In the atrophic form, the more frequent in the shoulder, there is rarefaction of the hone even to the complete disappearance of the articular surfaces, so thai the shoulder-joint atrophies the same as in caries sicca. Spontaneous dislocation is not unusual and may become chronic or habitual, in that the patient can produce and reduce it at will. Among the 12 cases in v. Brims' clinic there were 6 dislocations. Previously Schrader collected Fig. 61. The shoulder-joint in syringomyelia, (y. Bruns.) 15 cases in connection with 2 seen in v. Brims' clinic. The displacement of the deformed head may be extreme. As in arthritis deformans, the amount of effusion varies greatly; there may be no effusion or a moderate hydrarthrosis combined with bursitis of the subdeltoid bursa. Symptoms. — Aside from the evident deformity the most marked feature is the painlessness of the fully developed affection. There is something uncanny in the reckless manner in wdiich the patients sometimes go Vol. III.— 7 98 DISEASES OF THE SHOULDER. about with their deformed limbs; the use of the arm, however, is often surprisingly good in comparison with the severity of the deformity, providing that it is not compromised by paralyses or mutilation of the fingers. As a prodromal sign there are often violent attacks or crises of pain. Diagnosis. — The diagnosis is simple. The striking changes in the joint combined with the absence of pain should suggest a central disease to the experienced. Atrophic paralyses of the upper, spastic paralyses of the lower extremities, abolition of pain-sense and temperature-sense, multiple panaritia and their effects in the form of mutilations of the fingers — the Morvan type— verify syringomyelia; in other rare cases, as related, the well-known symptoms of tabes will be found. Prognosis. — The prognosis for the affected joint is absolutely bad, although the course may vary greatly; one occasionally sees patients in whom the changes in the joint have reached a high grade in a relatively short time and yet which after years are apparently stationary. Sup- puration and perforation are rather frequent. A great opportunity for infection is given in the multiple panaritia and numerous injuries of the skin which remain unnoticed on account of the analgesia. As to the treatment: the author has not attempted operation in his own cases in spite of occasional favorable results reported of resection; still, the latter may be rendered inevitable by suppuration of the joint, as in Czerny's cases, if it cannot be checked by antiseptic irrigation. In one case the author found amputation necessary for a simultaneous luxation of the elbow with fistulas. Protective apparatus may be demanded for a very loose joint or a tendency to dislocation. Thanks to the analgesia, any necessary operations can be done without anaesthesia. CONTRACTURE AND ANKYLOSIS OF THE SHOULDER- JOINT. Stiffness of the shoulder may develop after slight injuries of the joint, after contusions, sprains, dislocations, and intra-articular fractures; also after various inflammatory processes, as mentioned, and after periar- ticular diseases. The development of a contracture may be overlooked, as the arm by its weight lies against the thorax and the patient often deceives himself about its movements in believing that the joint moves, whereas the arm is abducted by the rotation of the scapula, so that the impairment of motion is frequently not discovered until a rapid muscular atrophy occasions a careful examination. Contracture at the shoulder may be produced by cicatricial contrac- tion and processes causing shrinkage of the skin and soft parts. In the large majority of cases, however, it is due to traumatic or pathological changes in the joint itself, cicatricial and callous shrinkage of the capsule and soft parts about the joint, especially at the lower part, hindering ele- vation and rotation of the arm. In the severer cases there are also defects in the cartilage, osteophytes, and fibrous growths producing fibrous and later bony adhesions between the articular surfaces. <<>S TRACTURE AM) AXh'YLOSIS OF Till: silo I'LDER-JoI.XT. 99 The author has indicated on page 46 the important part assumed by modern accident insurance in the subject of stiff shoulder. In order to estimate the disability caused by still' shoulder, Thiem states that the ability to lift the arm to a horizontal position enables the patient to do general work, and that an arm abductible to a horizontal and other- wise unimpaired is reduced about one-third in its usefulness. Complete stiffness of the shoulder-joint, the other joints being unimpaired, permits of motion and prehension only in the anterior lower third of the normal sphere of motion, the disability thus being slightly above 75 per cent. Such a range of activity, however, i> better than none. The kind of work done by the receiver of the annuity is also important in estimating the latter. These patients are much hindered in the ordinary daily routine. If the ankylosis occurs in youth, the entire shoulder zone is retarded in growth as well as that side of the thorax, so that later there may be pronounced asymmetry. Treatment. — The prophylaxis is of first importance; early massage, later passive motion, the latter often making great demands upon the surgeon and patient. The scapula and clavicle are held firmly with one hand, the other grasps the semiflexed elbow, and the movement of the arm is gradually increased in all directions. This is the best way of preventing the shrinkage of fibrous growths and the formation of fibrous adhesions. The tendency to muscular atrophy is combated by early local faradism, especially of the deltoid. The treatment is much more effectual if the patient can be made to aid actively in the movements. This is particularly difficult with regard to elevation, as few people possess the will-power to disregard and overcome the pain. They usually allow the arm to drop helplessly in the first attempt or deceive themselves and the surgeon by bending the spinal column and rotating the scapula. The surgeon is therefore obliged to resort to various artifices, among which Bardenheuer's method, especially recommended by Thiem, the author has used many times with success. The patient folds the hands together and with the elbows extended lifts the arms as high as possible over the head and holds them there for some time. The affected arm is at first elevated by the other, but is later obliged to assist as the latter becomes tired. The exercise should be repeated as often as possible daily. In the case of recently reduced dislocations Thiem advises that in the first few days during the exercise compression should be made at the joint to prevent dislocation. After some progress has been made staff exer- cises as recommended by Hoffa are very good to produce active mobili- zation. Gentle stretching of the shrunken soft parts can be effected by con- tinuous extension applied in the intervals between the exercises and dur- ing the night. The gentlest, least painful, and most satisfactory way of overcoming the contracture is by means of apparatus such as Reibmayr's with elastic traction; or Hoffa 's with screw appliances; or the Zander system as constructed by Hoffa, Beely, Ritschl, and others; or Kruken- berg's pendulum movements. Such apparatus are serviceable only in medico-mechanical institutes and hospitals, so that their full description 100 DISEASES OF THE SHOULDER. is unnecessary here. Bier's passive congestion is a valuable aid in the medico-mechanical treatment, and besides its well-known action in alle- viating pain, it produces marked succulence of the shrunken soft parts, so that they become more plastic and extensible. At the onset a muscular contracture may resemble a true ankylosis, so that anaesthesia is often necessary to determine the amount of contracture; at the same time mobilization may be begun by gentle motion. The formerly customary method of forcible tearing has been abandoned, as the lesions of the tissues thus produced cause renewed inflammatory irritation and hin- dered the medico-mechanical treatment; where the ankylosis is resistant the method has often caused fracture and fat-embolism. Firm fibrous and bony ankylosis are not amenable to the above methods of treatment. Resection is necessary; in favorable cases the restoration of function may be more or less complete. On the other hand, a loose joint may result and the remaining active control of the arm, as previously effected by the movements of the scapula, is fully lost. Consequently the surgeon is seeking merely a functional improve- ment and not the removal of diseased tissue; thus, this most valuable aid — namely, resection — becomes a two-edged sword and involves a heavy responsibility in determining its indication. Where the age, gen- eral condition, and mental disposition or environment seem to denote that the subsequent treatment essential to a good functional result cannot be carried out, it is better not to operate. The local indication depends, first of all, upon whether the muscles of the shoulder, especially the deltoid, are functionally adequate — electrical test; if they are not, resection would be a mistake. Likewise the technic of operation should have strict regard for the subsequent muscular function. LOOSE SHOULDER-JOINT. A loose joint may be the result of extensive loss of bone following fracture, gunshot-injury, resection; also of relaxation of the capsule fol- lowing inflammatory effusions, inflammatory destruction of the capsule, or deformity of the head (arthritis deformans and neurotica). The most frequent cause of loose joint is paralysis of the shoulder muscles, espe- cially the tensors of the capsule. It follows injuries of the circumflex, the suprascapular, or the brachial plexus; also intrapartum separation of the epiphysis, or it may be acquired later in life. The deformity is seldom so great in adults as in the young. The severest cases result from infantile spinal paralysis. Symptoms. — The arch of the shoulder is flattened, the acromion pro- jects forward sharply, and between it and the sunken head of the humerus there is a more or less pronounced depression, often sufficiently wide to admit two fingers. (Fig. 62.) The arm usually hangs relaxed and commonly rotated inward ; the hand is pronated ; active elevation of the arm is impossible; motion is limited to pendulous movements of the arm as a whole. Passively the mobility is abnormal, the head of the LOOSE SHOULDER JOINT. 101 humerus can be dislocated in all Fig. 62. directions and can be pushed up to its normal position, but sinks again to the position allowed by the relaxed capsule. Prognosis. — The prognosis is un- favorable. The condition becomes worse with age; the head of the hu- merus drops farther away from the acromion. The development of the shoulder, the arm, and the same side of the trunk is retarded. Treatment. — The treatment is usu- ally limited to orthopedic and medico- mechanical measures. Zabludowski speaks highly of the results obtained, even in cases of long standing, by strengthening the atrophic muscles and the traction pow r er of the auxil- iary muscles. To hold the head in the best possible position, various apparatus are proposed. Hoffa rec- ommends the appliance proposed by Schtissler (Fig. 63); by means of this a patient who had had a severe paralysis for six and a half years was able to write, draw, and play the piano. The apparatus consists essentially of a shoulder-ring, on the inner surface of wdiich three air-cushions are applied; of these, the Loose shoulder-joint from paralysis. (Hoffa.) Fig. 63. Schiissler's apparatus for loose shoultler-joint. two smaller triangular pads are placed in front and behind with the apex pointing toward the axilla; the third, large and rounded pyram- 102 DISEASES OF THE SHOULDER. idal shaped, is placed in the axilla and supports the head of the hu- merus. Billroth'- apparatus is shown in Fig. 04. Collin's is similar. Other apparatus hold the head up by means of rubber bands. Fig. 64. Billroth'? apparatus for loose Bhoulder-joint. Arthrodesis was performed unsuccessfully by Albert in 1879; success- fully by J. Wolff and Karewski. The head of the humerus is sutured to the glenoid cavity and if possible to the acromion with silver wire; the capsule is shortened by partial excision. Hoffa obtained improve- ment by splitting up a part of the insertion of the trapezius and implanting it in the deltoid. NEUROSES OF THE SHOULDER-JOINT. Joint-neuroses, which are regarded as hysterical and have been made known chiefly by Esmarch as a painful disease of the joint without anatomical basis, are met with in the shoulder. They occur very seldom here, as compared with their frequency in the hip and knee. In SO cases collected by Esmarch only 4 involved the shoulder. The pains are mostly of a drawing and tearing character radiating to the finger- tips and into the neck; they disappear as a rule after exertion, rarely prevent sleep, and become more severe if attention is paid to the patient. There is sometimes a certain amount of hypersesthesia; the affected part is more sensitive to slight touch than to strong pressure. The plexus is especially sensitive to pressure in Mohrenheim's space; the bicipital groove is not tender as it is in inflammation of the NE UR OSES ( > F Til E S II ULDER J01 A T. 1 Q3 shoulder-joint. The pain elicited by pressing the articular surfaces together, so marked in inflammatory processes, is trifling. Objective phenomena may be absent or limited to a peculiar local (edema and occasional, strikingly periodic temperature-changes in the entire limb or the joint. Functionally there is a feeling of weakness; elevation <>t' the arm is impossible; the scapula participates in passive movement, as in the case of inflammation. The diagnosis of joint- neurosis is justifiable only after prolonged observation and accurate examination have failed to detect organic changes. It must he con- stantly held in mind that changes in the bon( — caries sicca, gummatous ostitis — as well as a beginning synovitis may he accompanied by severe pain, although the objective findings are completely negative for a long while. Treatment. — ( General and psychical treatment are often of chief im- portance; secondarily massage, short cold sea-baths, medico-mechanical treatment. Local rest is valueless; on the other hand, improvement is usually rapid as soon as the patient is compelled to use the arm. CHAPTER III. OPERATIONS ON THE SHOULDER. LIGATION OF THE SUBCLAVIAN ARTERY BENEATH THE CLAVICLE. This operation is more difficult than ligation above the clavicle on account of the depth of the wound, particularly in muscular subjects, and the number of veins. The incision begins h inch below the highest point of the clavicle and runs to the coracoid process. The cephalic vein at the anterior border of the deltoid is retracted and the clavicular and platysmal portion of the pectoralis major are divided in the direction Fig. 65. Ligation of the subclavian beneath the clavicle D. Deltoid. M. Median nerve. A. Subclavian artery. V. Subclavian vein. F. External anterior thoracic nerve. (Kocher.) of the wound. The cephalic vein, anterior thoracic nerves, and branches of the acromiothoracic artery are drawn upward, the coracoclavicular fascia separated, and the upper border of the pectoralis minor exposed. The median nerve is drawn outward, the vein to its inner side drawn inward, the artery exposed beneath, and the aneurism-needle passed under from the inner side. (Fig. 65.) Kocher gives also a longitudinal incision along the groove between the deltoid and pectoralis; Chamber- (104) LIGATION OF THE AXILLARY ARTERY. 105 lain recommends a two-limbed incision along the clavicle and the above groove. If the dissection is difficult, especially in the case of the so-called diffuse aneurism following injury of the subclavian artery, a vertical incision with temporary resection of the clavicle and division of the pectoralis is advisable. The collateral circulation is usually established after ligation of the subclavian artery through the anastomoses of the terminal branches of the suprascapular and superficial cervical with those of the subscapular, intercostals, and thoracic. If it is necessary to ligate the artery above the exit of the subscapular — for example, if this artery is torn — gangrene of the arm may occur; the danger of this, however, is usually slight even if there is a simultaneous injury of the subclavian; in 90 cases of ligation of the subclavian v. Bergmann saw only 3 cases of gangrene of the fingers referable to it. LIGATION OF THE AXILLAE Y ARTERY. The arm is supinated and abducted and an incision 2h inches long made along the inner border of the coracobrachialis. (Fig. 66.) On separating the fascia a bundle of nerves containing the axillary artery is seen beneath; the sheath is separated and the anterior strand — the median and musculocutaneous nerves — is drawn forward; the posterior strand A R V Ligation of the axillary artery. M. Median nerve. Cm. Internal cutaneous. J?. Ulnar nerve. Cb. Coracobrachialis muscle. A and V. Axillary artery and vein. — the ulnar and musculospinal — is drawn backward and the sheath of the artery opened. The vein lies farther back at the posterior border of the plexus and sometimes divides into branches. If the incision is made too far back and opens upon the plexus the anterior edge of the wound must be drawn forward until the coracobrachialis and median 10G OPERATIONS ON THE SHOULDER. nerve are exposed. Less frequently the exploration and ligation of smaller vessels of the shoulder will require a special procedure. The posterior circumflex artery is easily reached by an incision carried through the skin and fascia 1 inch above the latissimus and along the posterior border of the deltoid. The deltoid is pulled forward and out- ward until the posterior border of the long head of the triceps is seen. The outer border of the scapula is then approached between the teres major and minor and the artery found close to the bone underneath the teres minor by incising the fascia. The suprascapular is found, at a point corresponding to the anterior border of the trapezius, close behind the upper border of the clavicle and beneath the lower belly of the omohyoid. RESECTION OF THE SHOULDER-JOINT. In resecting for injuries or pathological processes in which it is not necessary to remove all the adjacent tissues (as in the case of malignant neoplasms), regard for the latter function requires that the muscular attachments should be left intact with the periosteum as far as possible. This is done in a typical manner by the subperiosteal resection methods of Langenbeck and Oilier, and is applicable in the majority of cases. Resection with an Anterior Incision. — Langenbeck's incision begins at the anterior border of the acromion, descends 2\ to 4 inches along the bicipital groove, and penetrates between the fibres of the deltoid to the sheath of the biceps. The latter is opened at the inner border of the groove, divided upward to the origin of the long head on the glenoid margin, and the tendon then drawn out and to the inner side. The arm is rotated outward strongly and the periosteum together with the attach- ment of the subscapularis separated from the lesser tuberosity; in the same manner with the arm rotated inward, the attachments of the supraspinatus, infraspinatus, and teres minor are separated from the greater tuberosity. The muscular insertions will be preserved better in their natural relationship if the tuberosities are chiselled off, as advised by Tiling, or the superficial lamina of bone is peeled off with a sharp raspatory — "subcortical resection" of Kocher. The head is then dis- located, protruded from the wound, and sawed off. Oilier recommends in place of the long incision an oblique incision beginning at the clavicle and following the anterior border of the deltoid. The cephalic vein is drawn inward. The deltoid is hooked back just below its origin at the clavicle and a branch of the acromiothoracic artery beneath ligated. The muscle is drawn outward and the bicipital groove exposed. (Fig. 67.) The incision has the advantage of preserv- ing the deltoid and its nerve intact, whereas in the longitudinal incision through the muscle the circumflex nerve, winding around the posterior surface of the neck and entering the under surface of the muscle to supply the portion lying in front of the incision, is cut. Resection with a Posterior Incision. — Kocher incises from the acromioclavicular joint over the arch of the shoulder along the spine of RESKCTIOX OF THE SHOULDER JOIST. 107 the scapula to its middle, thence in ;i curve downward to the posterior fold of the axilla. The acromial joint is opened, the trapezius divided on the upper edge of the spine, the posterior border of the deltoid pulled forward, and after blunt elevation of the supraspinatus and infraspinatus the spine is chiselled oil", the suprascapular nerve being protected, and the acromiodeltoid flap swung out over the head of the humerus, to be sutured in place after resection is completed. Instead of resecting the spine temporarily the deltoid may he lifted off by chiselling off the hone subcorticallv. The capsule at the posterior border of the bicipital groove — anterior border of the supraspinatus muscle — is divided up to the glenoid margin and the outward rotators elevated from the greater tuberosity, and if necessary the subscapulars from the lesser tuberosity. The chief advantages claimed by Kocher for this method, Resection of the shoulder-joint (Ollier's incision): a, short head of biceps and eoracobraehi- alis; b. clavicle; c, coracoid process ; d, head of humerus ; e, point at which to divide capsule on anatomical neck; /, bicipital groove; g, long biceps tendon; h, deltoid; i, tendon of pectoralis; k, cephalic vein. (Kocher.) aside from the protection of all the important structures, are the free accessibility of the glenoid cavity for operations and the possibility of protecting the anterior portion of the capsule, the coracohumeral liga- ment, and attachment of the subscapulars. Bardenheuer's transverse incision differs from Kocher's in that the incision lies somewhat more forward, beginning at the coracoid process and ending 1 inch below the point at which the acromion process is attached to the scapula. Resection with Inferior Incision. — For old dislocations Langenbeck recommends a longitudinal incision at the posterior border of the cora- cobrachialis, through which the dislocated head is approached imme- diately beneath the axillary fascia. 1Q$ OPERATIONS ON THE SHOULDER. The termination of the operation with the removal of the head will depend upon the conditions; tuberculosis will demand careful inspection of the cavity, the removal of the diseased tissue with the scalpel, scissors, and sharp spoon, and if the foci cannot he cleaned out with a sharp spoon, resection of the diseased glenoid portion. Konig notes that in such extensive operations it may be necessary to ligate the posterior circum- flex artery; the same applies to the anterior circumflex if the operation is carried down upon the humerus (cave nerv. circumflex.!). In general the author removes as little of the head as possible, in contrast to the typical infratubereular resection, as the danger of displacement beneath the coracoid process and of loose joint increases with the amount of bone resected. In children particularly it is important to preserve the epiphyseal line, as the growth of the humerus in length depends chiefly upon the upper epiphysis. These conservative principles are hardly reconcilable with Htiter's proposal to expose the neck subperiosteal^' first, divide the head with a pointed saw, and then remove it, but where the ankylosis is very firm this may be necessary. How far the wound will be sutured primarily will depend upon the case; it is advisable under all circumstances to leave an opening for drainage at the lower posterior end at the border of the latissimus, the most favorable point; in the anterior longitudinal incision the lower angle of the wound can be left open. Great stress should be laid upon careful after-treatment. In applying the first bandage a cotton pad should be placed in the axilla to prevent inward displacement of the resected humerus. Extension is advocated by many. As soon as the wound is healed, massage, electricity, and careful passive motion should be instituted; active movements of the fingers, the hand, and the elbow should begin earlier. The upper end of the humerus should not be moved until the end of the fourth week, and then under accurate control and with gradual increase. Other things being equal the functional result depends chiefly upon the sub- sequent exercise and electricity; in fact, a passively loose joint can still be made useful if properly treated, as shown by v. Langenbeck. The earlier statistics of the mortality following resection of the shoulder — namely, in military practice an average of 35 per cent., in pathological processes 18 per cent. — are no longer applicable. Resection of the shoulder is to-day a relatively safe operation. The excellent functional results reported by v. Langenbeck, Volkmann, and Oilier, and the com- plete nearthroses verified anatomically by Textor and Oilier, are en- couraging for a broader application of resection, particularly for extensive diseases of the shoulder with suppuration and fistulas. AMPUTATION AT THE SHOULDER. Exarticulation of the arm may be indicated by injuries, particularly those produced by heavy ordnance, crushing, etc., and by various diseases — septic processes, tumors. The methods of amputation are numerous; AMPUTATION AT THE SHOULDER. [09 further, the individual type may be greatly modified under circum- stances. The method will always be chosen which gives the quickest control of the large vessels, as digital compression of the subclavian during the operation is never certain. The laceration of the soft parts produced by severe crushing, bombshell injuries, etc., may be so exten- sive that the vessels lie free in the wound or are lorn and require imme- diate ligation. Amputation Preceded by High Amputation of the Upper Arm.— The Esmarch bandage is applied like a spica around the arm, the end fastened upon the other side of the thorax, or, better, held by an assistant in order not to interfere with breathing; a single circular incision is made at the level of the anterior fold of the axilla, the vessels ligated, and the bandage removed. An anterior resection incision is then added, the upper end of the humerus removed (see the technic of resection), and the operation completed. As a rule the high amputation can he done away with, as the hemorrhage can he controlled accurately without the Esmarch by the following method: Amputation by the Oval Method (Kocher's Anterior Lancet Inci- sion). — Through a longitudinal incision beginning at the inner side of the coracoid process the anterior fibres of the deltoid are divided, the cephalic vein ligated; the incision is then carried down to the bone from the margin of the deltoid, the capsule separated in front of the bicipital groove and lifted off with the tendon of the subscapularis, the attach- ment of the pectoralis major, the latissimus, and teres major. The capsule upon the summit of the head and behind the greater tuberosity, the attachments of the supraspinatus, infraspinatus, and teres minor are divided, the head of the humerus dislocated outward, and the skin inci- sion completed by a circular cut at the level of the axillary fold. This in- cision is only through the skin, so that the nerve-sheath and vessel-sheath can be isolated, the vessels ligated, and the nerves divided. Care should be taken to avoid the circumflex winding about the head above the teres major and running to the deltoid. At the beginning of the operation the vessels may be ligated at the lower border of the pectoralis minor without difficulty, as proposed by Hiiter. If in the case concerned the soft parts can be preserved, subperiosteal excision of the bone and the preservation of the natural attachment of the muscles to the periosteum have the great advantage of giving a well-formed and more movable stump and permit of better application of the prothesis. Amputation with a Flap Incision. — The U-formed flap incision of Langenbeck, encircling and including the entire deltoid, is the one most generally used. The incision is made with a medium-sized amputation- knife beginning at the coracoid process and encircling the deltoid to end at the spine of the scapula. The knife is held obliquely throughout in order that the skin-flap may be greater than the muscular flap. The flap is then turned upward, the joint opened from above, and the head pushed out so as to allow the introduction of the knife behind. An assistant compresses the axillary bridge of soft parts containing the vessels with the thumbs in the wound and the other fingers in the axilla, HO OPERATIONS ON THE SHOULDER. while the knife is drawn downward close against the bone and then through into the axilla to form a small axillary flap; the vessels are then ligated. Defects of the soft parts which compel a flap incision may also neces- sitate an atypical operation, as the skin will have to be used where it is found. In the case of malignant tumors preventing preservation of the muscles, the most natural method will be the formation of an upper large skin-flap to cover in the wound. Where the tumor has extended beyond the bone, it is self-understood that careful dissection is necessary. Robuchon estimates the mortality of primary amputation in various wars at 50 per cent.; Fischer gives 66 per cent.; Schede, 24 per cent, for primary and 47 per cent, for secondary amputation. Naturally the results during the antiseptic era are much better; Schede cites 9 and Bardenheuer 12 amputations of the arm with only 1 death. Accord- ing to Scudder's statistics from the Massachusetts General Hospital, the mortality from amputations for trauma was 32 per cent, in contrast to 53 per cent, during the preantiseptic period, and from amputations for pathological processes per cent. RESECTION AND EXCISION OF THE CLAVICLE. Resection of the Sternal Joint. — This may be necessary in caries of the joint or to give access to the deeper structures. The incision is made parallel to the long axis of the clavicle and down to the joint, and is supplemented if necessary by a short vertical incision at its inner end; the periosteum is lifted off, the sternal end pulled out with the elevator and removed, or the clavicle is sawed off with a Gigli saw at an appro- priate distance from the joint. The outer end of the sternal piece is seized with forceps and separated carefully with the raspatory and bone-knife from the soft parts, the jugular vein being avoided. In extracapsular resection the venous arch of the jugulars should be guarded. The diseased articular surface of the sternum is best chiselled off from above forward and outward, and if displacement of the clavicular stump is apprehended, the bones should be united with a wire suture. Resection of the Acromial Joint. — This operation may be necessary for caries or for old or troublesome dislocations of the clavicle. Through an incision on the anterior surface of the outer end of the clavicle the periosteum is stripped off, the ligaments of the joint divided, and the end of the bone sawed off; all diseased portions are removed with the saw or rongeur. The stump is either sutured in place with silver wire or the ligaments merely sutured over it. Excision of the Clavicle. — Removal of the clavicle may be necessary in caries or necrosis, more commonly for malignant neoplasms. As done subperiosteally for necrosis the operation is simple. In removing tumors involving the periosteum and the adjacent muscles the subclavian vein and the pleura of the apex must be avoided. Through a longitudinal incision running the length of the bone the acromioclavicular joint is RESECTION OF THE SCAPULA. \\\ first opened, the clavicle is then pulled upward forcibly and separated gradually from without inward from the deltoid and pectoralis major. The coracoclavicular ligament is divided and the subclavian muscle and costoclavicular ligaments are freed, the adjacent structures being mean- while avoided. The trapezius and cleidal portion of the sternomastoid are freed from the upper border. Resection of the Clavicle in Continuity.— Generally it is best to resect subperiosteally if possible through an anterior longitudinal inci- sion and use the Gigli saw, as it is difficult to chisel the hard bone. If the saw-line is made oblique or zigzag, it is easier to suture and to prevent overlapping of the surfaces. RESECTION OF THE SCAPULA. Total Resection. — The chief indication is given by malignant neo- plasms involving the larger portion of the scapula. If the axillary glands are involved, they are also removed; the operation is not possible if the tumor has invaded the axillary vessels — which happens in about one- third of the cases — or if the tumor has spread to the shoulder-joint and arm. Extirpation is necessary less frequently for inflammations of the bone (Escher, Paci, Oilier), tuberculosis (Ceci), necrosis following typhoid (Duplay), and exceptionally for injuries from heavy ordnance (v. Langenbeck) or gunshot- w r ounds in general (Whelan, Douglas, Bennet, and others). In operations for injuries and inflammatory affections, the bony processes (acromion, coracoid), to which the muscles are attached, are preserved with their periosteum as far as possible, whereas malignant tumors demand radical removal of all involved tissue. The majority of operators prefer an incision along the spine and inner border of the scapula. A curved incision is made from the acromion along the spine to the internal border and then downward to the angle of the scapula. If the acromion is to be preserved, it is chiselled off; if it is to be removed, the incision begins by opening the acromiocla- vicular joint. The triangular flap thus made is drawn down and outward to the border of the latissimus, the deltoid lifted upon the fingers and divided, and the posterior surface of the capsule and the tendons of the outward rotators exposed. The muscles are divided in order upon an elevator or the fingers, and if the joint-portion of the scapula is to be preserved, it is sawed off. If the resection is for a tumor, the tendons of the rotators are separated from the head of the humerus, as in resec- tion of the humerus; below, the attachment of the latissimus dorsi and teres major are separated from the lesser tuberosity, the circumflex nerve and artery protected at the lower border of the teres minor, and the artery then ligated farther back. The trapezius is separated from the spine and the acromial branches of the acromiothoracic artery tied at the outer end. The scapula is then drawn down and the muscles attached to its upper border divided; the omohyoid and levator scapulae 112 OPERA TIONS ON THE SHO ULDEB. are freed from the upper angle and the terminal branch of the suprascapular and the branches of the dorsal artery of the scapula tied. The scapula is then turned over, the attachment of the serratus major on the posterior border and the attachments of the rhomboids divided and the dorsal artery, running along the border of the scapula upon the serratus, tied. All skin affected in the case of neoplasms is removed with a margin of healthy skin and appropriate flaps formed. The prognosis varies in the statistics published. In the pre-antiseptic period the mortality from the operation was 17 per cent., recoveries 30 per cent.; in the antiseptic period the mortality from operation is 7 per cent., recoveries 64 per cent. The statistics of various authors show rather wide deviations from these figures. The functional result was generally good. The statistics of Adelmann, Gies, Putti, and Poinsot show good function of the arm in about 65 per cent, of the cases. Partial Resection. — Amputation of the scapula with preservation of the joint has already been described. Resection of the acromion and spine is effected through an incision along the spine; in the case of tumors the periosteum and all involved adjacent tissues are removed. Resection of the angle of the scapula is done through an oblique incision, prolonged vertically if necessary, or through an angular incision following the line of the scapula. For resection of the joint-portion Esmarch and Vogt have suggested several methods: Esmarch makes a curved incision \ inch from the tip of the acromion, along its lower border and extending 4 inches backward; he divides the fibres of the deltoid at its attach- ment; exposes the posterior part of the capsule from above, opens it in the sagittal line between the tendons of the supraspinatus and infra- spinatus to about the middle of the greater tuberosity, and divides the overlying soft parts to the same extent. In the angular incision of Kocher (see page 106) the longitudinal division of the deltoid is avoided; the periosteum of the neck of the scapula is incised and separated with the capsule and biceps tendon from the bone. The edges of the wound are drawn well apart and the bone sawed through with the pointed or Gigli saw. The wound is closed except for drainage at the lower angle. By Vogt's method the entire anterior and outer portion of the deltoid are uninjured; the joint is approached from behind through a simple transverse incision running from the posterior border of the acromion along the lower border of the spine. INTERSCAPULOTHORACIC AMPUTATION OF THE SHOULDER. The simultaneous removal of the upper extremity and the shoulder is preferable in many instances to exarticulation, now that it is pos- sible to avoid the chief dangers of the operation, namely, hemorrhage and entrance of air into the veins. The most frequent indication is malignant neoplasm, especially when it involves the upper end of the humerus, the joint, and the surrounding muscles or the axillary glands. Berger believes the operation is indicated for all malignant tumors of JNTEBSCAPULOTlIoll.U IC AMPUTATION OF siioULDER. H3 the upper end of the humerus, as the chances are better if the radical operation is done at the outset and not after other operations. Its indication for sarcoma of the humerus lias been determined accurately by Xasse's histological demonstration of the tendency to metastasis in the muscles, hence the necessity of removing all the muscles of the arm leading to the thorax. It is also indicated for tumors of the scapula which have involved the muscles, the axilla, or soft parts, and which are Fig. 68. Interscapulothoracic amputation. a. transversal is colli artery; 6, omohyoid; c, 9erratus anticus; d, trapezius; e, subscapulars; /. deltoid; g, coracoid process; h and n, pectoralis minor; i, biceps; k and o, pectoralis major; /, median nerve; m, p, q, axillary artery and vein; dotted liDe ( ), posterior incision. (Kocher.) beyond the compass of total resection of the scapula. In carcinoma of the breast with extensive involvement of the axilla or of the arm, the operation is justifiable in the attempt to save life. It is indicated further in severe injuries, severe compound fracture of the scapula with extensive laceration of the soft parts and destruction or crushing of the upper extremity; in evulsion of the arm by machine accidents, railroad accidents, etc. Also destruction of the shoulder by heavy ordnance or severe burns and charring of the upper arm and shoulder may necessitate Vol. III.— S 1X4 OPERA TIONS ON THE SHO ULDER. amputation, as in a case of v. Bergmann's. The operation is counter- indicated by an unfavorable general condition; by infiltration of the wall of the thorax through the attached muscles; by extensive dissemination of the disease in the skin and subcutaneous tissue and in the glands of the supraclavicular fossa, and above all by general metastasis. In trau- matic cases with severe shock the operation is delayed or the exposed vessels merely ligated, as, for example, in total evulsion of the arm. If the hemorrhage is severe, the shock must be disregarded and its dangers combated by infusion. In the technic prevention of hemorrhage is of first importance. Simple digital compression of the subclavian artery in the supraclavicular fossa is uncertain, and the danger of air entering the vein must be avoided; consequently previous ligation of the subclavian artery and vein by resection of the middle portion of the clavicle, as first employed by Langenbeck in 1860, is the most reliable procedure. To Berger is due the credit of having elaborated the important details of the operation as published in his monograph in 1886. The various modifications pre- ferred by different operators are not essential ; the following description is the one given by Kocher and is practically the same as Berger's: The incision begins at the sternal end of the clavicle, runs to the acromion, and is later completed by an incision running downward and forward to the axilla and uniting at this point with the posterior limb running from the acromion — Kocher's lancet incision, dotted line. (Fig. 68.) Extensive injury of the skin or its involvement by tumors will demand various modifications of this incision. The first longitudinal incision divides the periosteum of the clavicle; the bone is divided at its inner third, pulled outward, and freed from the subclavius and trape- zius. The subclavius is separated in the direction of its fibres, the fascia incised, and the subclavian vessels and the plexus exposed. The indi- vidual nerves are divided, the vessels tied in two places and divided. To avoid hemorrhage, it is also advisable to ligate the branches of the thyroid axis running outward over the scaleni — ascending and superficial cervical and suprascapular — and the transversalis colli artery. The incision is now lengthened downward and forward toward the axilla, the pectoralis major and minor divided layer by layer, and all vessels clamped immediately. The axillary fat and glands are removed, the latissimus divided at the posterior edge of the axilla, and the entire anterior surface of the scapula made accessible by turning back the shoulder. At the inner border the levator scapulae, serratus anticus, and the rhomboids are divided from above downward; the inner border of the scapula is then drawn forward and outward, the trapezius separated from the spine, and the omohyoid divided. The skin is incised behind, as in Fig. 68, and the operation completed. The statistics of the operation are fairly numerous: Konitzer gives 133 cases, the majority of which were for sarcoma, with a mortality of 4 per cent. In 46 cases Berger experienced only 2 deaths; in 14 cases operated on in v. Bergmann's clinic only 1 was fatal, and in this the sarcoma had already invaded the vena cava. Even the more recent INTEBSCAPULOTHOBACIC AMPUTA TION OF SHO ULDER. 115 works show that recurrence is an ever present possibility, and that Konitzer's estimate of 30 per cent, recurrence is unfortunately consider- ably below the actuality. Buchanan (1900) gives 16 pei cent, mor- tality among is 1 cases, 131 of which were for tumors. Since 1875 the mortality in general is about 8 per cent. Fig. 69. Deformity after interscapulothoracic amputation. (Powers.) The deformity is naturally very marked. (Fig. 69.) Secondary scoliosis is rather frequent. A prothesis is sometimes beneficial. Collin constructed an apparatus consisting of a leather jacket and an artificial arm, the latter being hinged to the jacket by means of iron strips and movable forward, backward, and outward. An elastic band draws it against the side after it is moved. The elbow is jointed, and the thumb so constructed that it can be approximated against the other ringers or 116 OPERATIONS ON THE SHOULDER. extended by means of a catgut string running on pulleys obliquely across the back of the jacket and fastened to a band on the other arm. The apparatus of Lucas Championniere is simpler, consisting of a tight- fitting linen jacket with buckles. It is covered on the affected side with Deformity after interscapulothoracic amputation. (Powers.) leather, to which the arm is attached; it has no apparatus for the exten- sion of the thumb. By wearing such an apparatus the deformity is concealed, the patient is able to grasp, hold, and carry light objects, and can even do special work; Berger's patient worked as a postman for eighteen years afterward. CHAPTER IV. MALFORMATIONS OF THE UPFER ARM. Among the malformations of the arm should he mentioned amelia, or complete absence of all extremities, in which there are merely small wart-like protuberances or short stumps, whereas the trunk is well formed; abrachia, or absence of the arms; and monobrachia, or absence of one arm. Perobrachia signifies a rudimentary formation of the arm; the hand is often more or less well developed and projects from the trunk like the extremity of a seal — phocomelia; the malforma- tion may affect all four extremities or only the upper, and is more frequently bilateral. "Spontaneous amputation" may affect the upper arm, although less frequently than the forearm and lower extremity, and is produced by amniotic bands. Almost complete amputation has been produced by entanglement in the umbilical cord; in certain instances of spontaneous amputation the stump was pointed, the bones covered merely by cicatricial tissue and very sensitive. In hemimelia, in which in contrast to phocomelia the distal part of the extremity is lacking, there are usually small excrescences at the end representing the rudi- mentary fingers. Individuals with such rudimentary extremities often learn to hold a pen in the mouth, eat with their feet, and perform many kinds of work' they can do many things with a prothesis. "Congenital hypertrophy" is less frequent, and usually affects the thicker portions of the arm and is accompanied by dilatation of the vessels. Holmes refers such conditions to a disease of the vascular system or to processes such as lead to the development of congenital tumors. In some in- stances the disturbance was accompanied by thickening of the soft parts similar to elephantiasis or by the formation of circumscribed lipomata. According to Trelat, the hypertrophy involves chiefly the muscles and bones. (117; CHAPTER V. INJURIES OF THE UPPER ARM. INJURIES OF THE SOFT PARTS OF THE UPPER ARM. Ox account of its exposed position and manifold uses the arm is greatly subjected to external violence, and is freouentlv injured by contusions and wounds from sharp and blunt instruments. In contusion there may be extensive subcutaneous hemorrhage along the entire arm, especially on the inner side; tangential forces may produce more or less extensive avulsion of the skin from its substratum with or without subcutaneous extravasation of blood or lymph. In such instances the skin-pockets are not fully distended, the content can be easily moved about and collects mostly in the dependent portions. Fluctuation in the swelling is distinct, although soft, and often remains unchanged for a long time. Compressing bandages bring about prompt recovery; excep- tionally suppuration occurs and requires incision. Wounds from sharp instruments are not uncommon in the upper arm, and involve skin and subcutaneous tissue alone or also the muscles and nerves. If the subcutaneous veins bleed much, as sometimes happens, they must be ligated. Large clots should be turned out of the pockets. Simultaneous injuries of the arteries or nerves should always be thought of. In transverse or oblique wounds on the flexor surface of the arm the bandage should be applied with the elbow flexed; with the elbow ex- tended for wounds on the extensor surface. Extensive injuries of the skin, particularly avulsion by machinery, burns, anabrosis, etc., may be followed by severe contractures. Torn skin-flaps resulting from machinery accidents rarely heal even if the pedicle is broad, as usually the tissues are so badly damaged that gangrene follows. It is not advisable to suture such flaps in place; the chances are better if the retention suture is delayed several days. Large skin defects and sub- sequent granulating surfaces require Thiersch grafts or pedunculated skin-flaps brought over from the shoulder or thorax. INJURIES OF THE MUSCLES OF THE UPPER ARM. Wounds of Muscles. — Incised wounds of the muscles are frequently caused by scythes, knives, and sabre duels. There is usually partial division of one or more muscles combined with injuries of the nerves or vessels. The belly of the muscles is seldom entirely severed so that the ends retract in the wound. Although union has been seen where there was marked separation, it is better to suture the muscle in tiers ( US) INJURIES OF THE MUSCLES OF THE UPPER ARM. \ \\\ with strong catgut, preferably double, to prevent the sutures from tear- ing out. Hernia. — Hernia of the muscles sometimes occurs in subcutaneous or other injuries from the tearing of the fascia, and is recognizable by the presence of a small soft tumor which hardens during contraction, feels elastic during moderate contraction of the muscle, and subsides entirely during relaxation; the vent in the fascia can then be felt plainly. Such hernias produce little trouble, so that operation (suture of fascia) is rarely required. Rupture. — Rupture of the muscles is more serious, and takes place as a subcutaneous, partial or complete separation of individual muscles of the arm. It is usually the result of overexertion, namely, of a demand upon the muscle greater than its strength, whereby it is torn during contraction. It occurs almost exclusively in men; exceptionally Fig. 71. Rupture of the biceps, (v. Bruns.) in individuals with degenerated muscles — as in alcoholics — or at the site of previous injury, as, for example, after extirpation of a tumor. (Ceppi.) The biceps is most commonly affected, especially the long head. In 81 cases of muscular rupture collected by Maydl, there were 18 of the biceps. Loos recently collected 66 cases of rupture of the biceps, of which 2 were in women, in connection with 4 cases seen in v. Bruns' clinic. Among 56 of these cases, more fully described, there were only 2 of the short head, 1 of both heads, 3 of the common belly, and 3 of the distal tendon, in contrast to 49 of the long head. In the ktter cases the tear was in the upper tendon in 10, at the musculo- tendinous junction in 20, in the belly of the muscle in 17. Petit found the tendon of the long head ruptured in only 43 of 83 cases. Etiology. — The cause is usually overexertion, violent overstretching of the contracted muscle, as in lifting a heavy weight or throwing heavy 120 INJURIES OF THE UPPER ARM. bodies, as in bowling, etc. The rupture may result from the weight of the body, as in a case seen by Thiem of a man who was left suspended in the air by the breaking of a scaffold and then fell. Many regard inco-ordinated contraction of the muscle as a cause; in such cases the passive stretching of an actively contracted muscle, possibly in its mar- ginal bundles, cannot be excluded. Weber states that the coraco- brachialis and short head of the biceps of washerwomen are frequently torn while wringing clothes. The injury is accompanied sometimes by a distinct snap, sudden pain, and corresponding loss of function. Symptoms. —The deformity of the muscle is usually recognizable dur- ing contraction; there is a depression admitting the finger. In transverse ruptures in the upper part the approximation of the belly of the muscle to the elbow is noticeable compared with the other side. In ruptures of the lower half the upper end is drawn upward and forms a soft swelling that sometimes feels like a cyst. The muscle can be stroked back into its normal position with slight pressure. There is usually local hemorrhage spreading out into the surrounding tissues. Flexion of the arm is weaker in supination than in pronation. By the action of the brachialis the arm can be bent slowly but without power. Diagnosis. — The diagnosis of rupture of the biceps depends upon its sudden onset with pain, the deformity of the biceps, the evident cleft in the substance of the muscle, the increase of the same during exten- sion of the forearm, and upon the impaired flexion with the forearm supinated. With rupture of the tendon of the long head there is forward and inward partial dislocation of the humerus. Rupture of the triceps, although more rare, has been seen as the result of a fall upon the flexed arm, of slipping, and of falling while holding a basket. Rupture and tearing of the brachialis are of rather frequent occurrence in injuries of the elbow — fractures of the lower end of the humerus, sprains, etc. — and are evidenced by marked ecchymosis on the front and side of the forearm and lower third of the upper arm. Prognosis. — The prognosis is naturally more favorable in partial than in complete ruptures. In the majority of cases the function is fully restored, although persistent disability has been observed. If improperly treated, union may be by broad bridges of fibrous tissue, and the muscle become hour-glass shaped. Thiem estimates the annuity of cases with impairment of flexion at from 10 to 20 per cent. Treatment. — Treatment consists in approximating the surfaces by applving a flannel bandage — propulsive bandage — or adhesive strips, and immobilizing in the position of greatest relaxation. If the separation is marked, and particularly if it affects the tendinous portion, incision and suture are advisable. Besides rupture of the muscle, various other less noticeable injuries of a traumatic nature occur which are recognized chiefly by their sequela?; avulsion of the muscle with its periosteum may give rise to a process of ossification extending from the point of rupture over entire INJURIES OF THE VESSELS OF THE UPPER ARM. 121 groups <>!' muscles. In severe contusion of the arm produced by crushing between two rollers, as happens frequently in spinning and similar industries, the entire muscular parenchyma can be reduced to a pulp beneath the intact skin, so that it is later absorbed and replaced by cicatricial tissue, analogous to the process observed in ischemic degeneration. INJURIES OF THE VESSELS OF THE UPPER ARM. The brachial artery may be injured by puncture, incised, stab or gunshot-wounds, frequently in connection with injuries of the muscles, nerves or humerus. In warfare gunshot-wounds of the brachial artery are rather common. In American wars they represented 18 per cent., and in the Russo-Turkish War 25 per cent, of all vascular injuries. Diagnosis. — The diagnosis is simple in the presence of primary or secondary hemorrhage; in their absence the author relies chiefly upon the situation and direction of the wound, absence of pulsation in the distal part of the artery, coldness of the extremity, and in case of partial laceration of the artery he depends especially upon the oscultatory phenomena. Prognosis. — The prognosis is doubtful, as under circumstances there is danger of gangrene and sepsis or of the formation of a false aneurism; simultaneous injury of the veins and nerves makes it much less favor- able. Treatment. — The same general principles apply as described pre- viously under injuries of the vessels at a higher level; the possibilities here, however, of first aid and future operation are much better than in the axilla by reason of the accessibility of the arteries for digital compression and the elastic bandage. The danger of paralysis is to be remembered in applying the tourniquet. The rule is to find and double ligate the brachial at the site of injury; ligation above the exit of the profunda greatly increases the danger of gangrene, and should be employed only when a phlegmonous infection of the wound presents the danger of septic secondary hemorrhage. If the artery is merely punctured, it may be possible to suture it. Doerfler reports a case in which the edges of the wound forming flaps on either side of a half- severed artery were sutured successfully with four stitches. In simul- taneous injury of the brachial artery and vein an arteriovenous aneurism may develop. Subcutaneous Injuries of the Brachial Artery. — It is very seldom that severe contusion produces rupture of the brachial artery. Pautier saw a case of this sort, leading to gangrene and amputation, in a driver who, while intoxicated, fell off a heavy wagon, the wheel passing over the middle of his arm. Rupture of the inner and middle coats happens more often from severe crushing forces (run-over, buffer, and machinery accidents); at times it is followed by the formation of an aneurism, or by thrombosis and threatening gangrene, or by actual gangrene of the 122 INJURIES OF THE UPPER ARM. hand and forearm. The rupture may be due to stretching of the coats where the trauma acts solely upon the forearm. In the majority of cases there is also severe contusion and laceration of the muscles, or fracture. Such cases may have a medico-legal bearing in that the gangrene is easily referred to an apparently constricting bandage. Secondary disturbances — ischsemic muscular paralyses — may follow such subcutaneous injuries of the vessels of the arm. INJURIES OF THE NERVES OF THE UPPER ARM. On account of their superficial position the nerves of the upper arm are greatly exposed to injury, such as incised, penetrating, and stab- wounds; as from falling upon glass utensils, sharp-edged sheets of tin, iron, etc. They are occasionally damaged in operations if they have become enclosed in cicatricial tissue or forced out of their normal posi- tion; further, they may be empaled by sharp fragments in fractures. Blunt division and laceration of the nerves occur in gunshot and machinery injuries, especially in belting accidents. The division of the nerve may be complete or partial, clean cut and smooth, or frayed, oblique or transverse. The retraction of the stumps is usually slight except in old cases of division or laceration with loss of substance. Symptoms. — The symptoms are loss of motor and sensory function of the divided nerve. The sensory area is often supplied simultaneously by different nerves, so that the disturbance produced by the division of the nerve often affects only a portion of the area. The faradic and galvanic irritability of the divided nerve diminishes rapidly and soon ceases; degeneration is more or less pronounced and rapid. Course. — The course varies greatly in individual cases. Union of nerves by primary intention, namely, the immediate reunion of the axis- cylinders of the divided ends, even if they are accurately apposed, has not been verified. Recovery is effected by regeneration of the axis- cylinders of the proximal stump. The peripheral portion merely fur- nishes the path for the new nerve-formation. Prognosis. — The prognosis depends not only upon the nature of the division, the time elapsed, etc., but essentially upon the treatment. If regeneration occurs, the electrical irritability returns gradually and sen- sation is restored before mobility. Exceptionally the new fibres conduct motor impulses before they respond to electricity. Months, sometimes years, are required for complete restitution of mobility in the case of the nerves of the upper arm, whereas the first sign of returning motor function is usually evident in the third or fourth week. The more recent the injury and the quicker the union of the stumps, the better the outlook. Primary union particularly improves the prognosis; suppura- tion, in addition to destroying the stumps of the nerve, may lead to the production of fibrous tissue. Even in the cases of primary suture with favorable recovery trophic disturbances may appear later or the result may be only temporary. At all events, slight disturbances often persist INJUR IKS OF THE NERVES OF THE UPPER ARM. 123 in the hand. Division higher up is less favorable, as the more distal the lesion, the shorter is the portion to undergo regeneration. Treatment. — The treatmenl aims to establish the most favorable conditions for regeneration — that is, exaet apposition of the stumps. Although regeneration doubtless occurs without suture, the surgeon's dutv is to procure union by primary suture if possible. Nerve suture is a comparatively recent operation; yet the statistics, especially with regard to the arm, are fairly numerous; and although the justification and indication of suture were formerly open to discussion, at the present time the author regards it as the duty of the surgeon to suture in recent and often in old cases. The surgeon should be convinced that suture of the divided nerve is indicated as much as suture of the divided tendon. The circumstance that conduction is restored spontaneously so frequently after operative division of the sensory nerve of the face should not lead to the delusion that the same thing happens in the peripheral nerves in the extremities, as in the latter there is usually retraction of the ends and cicatrization or interposition of fibrous tissue that arrests the func- tion permanently. Failure to suture must be regarded as an error, as the operation has proved successful and extremely beneficial in more than two-thirds of the cases. Special measures are necessary -for defects in the nerve preventing approximation of the stumps. If the separation is slight — 1 to H inches — union may be obtained by stretching. (M. Schiiller.) If not, one should not hesitate to resect a part of the humerus; or if there is a fracture in the ease concerned, to shorten the ends. Plastic operations, namely, the formation of flaps (suture a lambeaux ou dedouplement), as for defects in the tendons (Xetievant), are not advisable, as the nerve is thus additionally injured and the conditions for regeneration made just so much more unfavorable. Transplantation of nerves, namely, implantation of sections of nerve from an animal (Gluck, Kaufmann, and others), or a section of spinal cord (Robson), is more experimental than practical. Vanlair's tubulization method furnishes conditions which favor regeneration; a decalcified sterile tube of bone (Lotheissen uses a tube of formalin gelatin, Payr one of magnesium) is used, into which the stumps are fastened; its value has been verified by Socin and others. For large defects nerve-grafting should be considered; the peripheral stump is implanted in another nerve. Depres implanted the distal stump of a torn median nerve between the separated fibres of the ulnar. Kolliker regarded this procedure as an unfortunate modification, as the healthy nerve is thus injured, and if the freshening of the fibres is insufficient they will not regenerate. These various procedures, employed chiefly by English surgeons (Harvey, Galbraith, Reed) under the name "neural infixation," require further trial before they can be rejected. If some time has elapsed since the injury, secondary suture is indi- cated if any considerable functional disturbance still exists. The results of secondary suture as reported in the literature are not less favorable than those of the primary — about 75 per cent, of recoveries. If the site 124 INJURIES OF THE UPPER ARM. of division is surrounded by much cicatricial tissue, secondary suture is often difficult. The area is best exposed by following along the nerve from above and below. It is important to remove entirely the cicatrized and degenerated parts of the stumps, and to protect the nerve against the pressure of a new cicatrix by shifting it into healthy tissue or sheathing it by tubulization. P. Bruns gives an important modification to avoid extensive resection and shortening of the nerve. In suturing the radial nerve secondarily he divided longitudinally the cicatricial band uniting the stumps, folded the divisions on each other laterally, and sutured them, thus approximating the stumps. If the proximal stump is club- shaped, v. Bruns recommends dividing it longitudinally up to normal nerve-fibre, tapering the distal stump, and inserting and suturing it in the cleft; the contact surface and security of the suture are thus increased. The after-treatment consists in immobilization for two or three weeks; later, massage and electricity to stimulate the atrophied muscles. Pressure-paralysis of the nerves of the arm is not uncommon on account of their superficial position. Such paralysis occurs repeatedly after application of the Esmarch bandage; during operation from pressure against the edge of the operating-table; in sleeping in a chair, from the arm resting against the chair-arm. Pressure-paralysis occurring during the union of fractures will be discussed later. Various occupa- tional injuries often produce paralyses by compression of the nerve. Bachon describes a typical paralysis in the water-carriers of Rennes; they carry the water in a large jar, the bottom of which is supported against the lower front part of the trunk, the arm being thrust through the handle and the jar pressed against the chest. In this way pressure is brought to bear upon the outer posterior surface of the arm, obliquely across the musculospiral, so that it is not surprising that the nerve is compressed. Besides pressure, various injuries affect the nerves of the upper arm (contusions, tears, displacement of the nerve), producing temporary dis- turbances (tingling, numbness, and paretic conditions) or severe neural- gias, spasms, or paralysis. The so-called neuralgia of venesection was formerly a well-known occurrence. (Bell, Brodie, Pirogoff.) Neuritic disturbances and severe pains are sometimes caused by cicatricial ad- hesions and fibrous tissue about the nerve — as occasionally happens after phlegmon — and by exostoses. In such cases neurolysis, namely, the freeing of the nerve from the compressing cicatrix or fibrous tissue, may be indicated. The formation of new adhesions should be prevented during the process of healing; there are many places — for example, the ulnar groove — where there is great danger of renewed compression follow- ing the operation, whereas between the muscles the conditions are much more favorable, as the muscular action mobilizes the cicatrix. It is generally a good plan to stretch the nerve moderately after separating it from its adhesions. Injuries of the Musculospiral Nerve, — From the axilla the musculo- spiral nerve runs between the long and inner head of the triceps on the posterior surface of the humerus, forms a spiral about the humerus, INJURIES OF THE NERVES OE THE UPPER ABM, 125 gives off muscular branches at the junction of the lower and middle thirds on the outer side, and enters the elbow to the outer side of the radial artery covered by the supinator longus, to course down the radial side of the forearm. It supplies the triceps, supinator longus and hrevis, extensor carpi radialis longus and hrevis, extensor communis, extensor carpi ulnaris, extensor pollicis longus and hrevis, and the extensor digitis indicis. It is the sensory nerve of the dorsum of the hand and fingers, except the little finger. Musculospiral paralysis is the most frequent and most important of the paralyses of the brachial plexus. In its spiral course around the outer side of the humerus the nerve is exposed to incised, puncture, and stab-wounds, and is very liable to injury in fractures, as will be discussed under complications of fracture of the humerus. Gunshot- wounds are unusual. Symptoms. — The first symptom of musculospiral paralysis is inability to extend the hand and fingers. The hand hangs in characteristic pro- nation and flexion — drop-wrist. The flexors soon prevail, so that as a rule a flexion contracture develops very promptly. The muscles supplied by the nerve atrophy; extension of the last two phalanges by the interossei — supplied by the deep branch of the ulnar — is still possible, but exten- sion of the basal phalanges is lost, so that the fingers are flexed at the metacarpophalangeal joints. Anaesthesia on the dorsum is more or less extensive, but may be slight on account of the anastomosis of the nerves and the so-called "supplementary function." In an old case Rusch found an anaesthetic area on the dorsum only J t inch in diameter. Exceptionally, trophic disturbances may supervene in old cases. From these symptoms the diagnosis is simple. In recent injuries, particularly fractures of the humerus, one should always test the condition of the nerve. Treatment. — Suture of the nerve gives good results even in cases of long standing. In comparison with suture of other nerves, it gives by far the best prognosis — 93 per cent, recoveries — not only with regard to the return of conduction, but also the degree of recovery. Kramer gives 4 failures in 42 cases of suture of the musculospiral, 12 failures in 50 of the median, and 8 in 32 of the ulnar. There were 32 recoveries in 35 operations for compression of the nerve, among which there were 2 resections. Busch reports a successful secondary suture four months after the injury, Sick the same six months after, Nussbaum nine months after, and Esmarch sixteen months after. In 1 instance in which it was impossible to unite the stumps by suture, Sick obtained a useful hand by suturing a bridge from the median to the distal stump of the musculo- spiral. If the first operation is not successful, all hopes should not be given up, as in many instances conduction is prevented by fibrous union, etc., and the paralysis overcome only by a second operation. There are always some cases which cannot be helped by operation. Thiem estimates a 45 to 50 per cent, accident annuity for such incurable paralysis. Formerly, apparatus was the sole aid for such incurable cases, the extensor paralysis of the hand and fingers being more or less overcome 126 INJURIES OF THE UPPER ARM. by means of elastic bands or springs. Good results are obtained at the present time by tendon-transplantation; Franke attests its particular value in musculospiral paralysis. He holds the hand mechanically in extension by shortening the tendon of the extensor carpi radialis and restores the extensibility of the fingers by transplanting a flexor tendon — for example, the flexor carpi ulnaris, which is easily drawn over to the extensor surface — into the tendons of the extensor communis. Active extension of the thumb can be obtained by transplanting half of the tendon of the flexor carpi radialis into the tendon of the long extensor of the thumb, the flexor carpi radialis being meanwhile stretched as tight as possible Fig. 72. Deformity from paralysis of the median nerve (ape-hand). Injuries of the Median Nerve. — The median nerve is not infre- quently divided in the upper arm by blunt or sharp violence, and is occasionally stretched or torn in fractures or by the projecting end of the humerus in posterior dislocation of the forearm. According to Fischer, the median nerve was involved 49 times in 189 gunshot injuries of the nerves of the upper extremities. Symptoms. — As the median nerve supplies the pronator teres and quadratus, the flexor muscles of the forearm (excepting the flexor carpi INJURIES OF THE NERVES OF THE UPPER ARM. 127 Fig. 73. ulnaris and the ulnar part of the flexor profundus), the muscles of the ball of the thumb (except the inner head of the flexor pollicis brevis), and is the sensory nerve of the radial half of the palm, division of the nerve is manifested chiefly by loss of flexion of the hand and fingers, inability to appose the thumb, and by anaesthesia of the larger part of the flexor surface of the forearm and hand. If the paralysis persists, there is atrophy of the flexor side of the forearm and of the hall of the thumb. By contraction of the extensors the thumb is abducted and extended — ape-hand. (Fig. 72.) Treatment. — Suture of the median nerve, primary or secondary, is a fairly frequent operation. As to its prognosis compared to suture of the musculospiral, see page 125. v. Brims sutured the median success- fully one year and nine months after injury. Injuries of the Ulnar Nerve.— The ulnar nerve is usually injured at the elbow, rarely in the upper arm; it may be damaged in fracture, especially oblique fracture of the con- dyles. According to Fischer, the nerve was injured 3 spiral; and those occurring later — secondary paralyses of the musculo- spiral. Primary Paralysis of the Musculospiral. — Surgeons distinguish ana- tomically between the cases in which the continuity of the nerve is retained and those in which it is lost. The latter are rare; in 7'.* cases v. Brims found only 3 of this sort. In the former ease there may be contusion of the nerve by external violence; tearing, or laceration by dislocated fragments, or the nerve may be interposed between the frag- ments or impaled by a sharp splinter. Even with apparent preservation of continuity the nerve-substance may be entirely crushed within the neurilemma. If there is separation of continuity, the nerve may be torn, contused, cut off clean by a sharp fragment, especially in torsion fracture, or crushed. Symptoms. — The symptoms of musculospiral injury vary according to the severity of the injury and the nature of the violence. In simple contusion there may be sensory disturbances and temporary paresis; usually, however, the characteristic picture of complete paralysis is seen. (See page 125.) In injury of the musculospiral high up the triceps may be affected, as in a case of high fracture seen by Middeldorpf. The very embarrassing position in which a surgeon may be placed by over- looking a primary musculospiral paralysis can be easily avoided by exercising proper care. It should be made a general rule without con- dition to test the musculospiral nerve in all fractures of the shaft of the humerus, particularly those of the middle and lower third. If possible, the nature of the injury causing the disturbance should also be deter- mined, a matter often difficult or impossible. Treatment. — The treatment is expectant. If interposition of the nerve between the fragments is suspected from the presence of severe nerve pains, an attempt should be made to free the nerve by manipu- lation — movements of extension and circumduction — as effected by Oilier in one instance. If this does not succeed, the nerve should be exposed. If there is no positive evidence of interposition the surgeon should await consolidation of the fracture, as it is usually impossible to determine whether there is a paralysis in continuity or division of the nerve. Usually the function is restored in from one to two months by the simple application of massage and electricity, and unnecessary operation is thus avoided. If restitution does not occur, secondary operation gives as favorable a prognosis as the primary procedure. Secondary Paralysis of the Musculospiral. — The term is only justified when one can be positive of the integrity of the nerve directly after the fracture. The cause of secondary paralysis is always pressure. There may be constricting cicatricial tissue pressing the nerve against the bone or fixing it against a sharp projecting fragment. There may be an abnormal growth of callus by which the nerve is pressed flat or crazed. The callus may form a tunnel about the nerve and compress it atone point or through its entire length. Exceptionally the nerve may be thinned out by a bony spicule projecting in the bony canal or it may be bent bayonet- shaped; it may be thinned and thickened in places alternately like a 134 INJURIES OF THE UPPER ARM. Fig. 81. pearl necklace or be enclosed immovably in a bony or fibrous canal and impaled by numerous spicules. In a single case of Czerny's the nerve was bent at an angle over a sharp fragment and worn off by motion. In 4 of his own cases Schreiber found the nerve bound by a cicatrix against a projection of callus. Symptoms. — In such cases due to pressure the signs of paralysis appear gradually dur- ing or after bony union, and are usually first recognized at the end of one or two weeks, or when the splint is removed in the fourth to sixth week. The sensory disturbance is often surprisingly slight. The .r-ray may aid in the diagnosis. Prognosis. — The prognosis is favorable only in the event of operation and removal of the compression by freeing the nerve from the cicatricial tissue or bony canal. Even in old cases hope should not be relinquished; Kennedy procured complete recovery at the end of a year, and Busch after sixteen months. Treatment. — For the treatment the author refers to the chapter on Injuries of the Nerves of the Arm, and only adds here that where the nerve is enclosed in a callus tunnel it Musculospinal nerve free i fn.m should be exposed distallvand proximallv callus at fracture of the humerus 1,1 p 11 1 • 11 1 mi i,y resecting the caiius. (oilier.) and then carefully chiselled out. The nerve is liable to be cut by the chisel, as the bony canal is often very irregular. If after resection and suture there is too much tension, a shorter path can be made by chiselling out a deep groove in the bone. If this is not sufficient, one has to choose between resection of the humerus and a plastic operation on the nerve. PSEUDARTHROSIS OF THE HUMERUS. Delayed union and pseudarthrosis are observed not infrequently in the humerus. In v. Brans' statistics of 1274 cases of ununited fractures there w r ere 376 of the humerus; among 681 authentic cases of pseudar- throsis there were 226 (33 per cent.) of the humerus. As the frequency of fractures of the humerus in general is only 15 per cent., this bone shows the greatest tendency to pseudarthrosis. Etiology. — The cause may be general or local; wide separation of the fragments, necrosis of interposed splinters or of the ends of the frag- ments, impalement of muscle by pointed fragments, muscular interpo- sition, insufficient fixation by improper splints. Exceptionally a nerve lesion — for example, laceration of the musculocutaneous — has been held rsl'A'DMlTlllloSIS OF THE HUMERUS. 135 responsible (Sneve); in aboul half the * IG - 82 - cases muscular interposition was at fault. (W. Meyer.) Anatomical Findings. — There is usually more or less thick fibrous tissue between the fragments; the latter often appear entirely without reaction or are covered by thin callus deposits. (Fig. 82.) At times the fragments are found to he necrotic or there are necrotic splinters lying between them. Rarely and only after long existence a new joint may be formed with complete cartilaginous disks, capsule, etc. (Fig. S3); even arthritis deformans with all its char- acteristics may develop in the newly formed joint. (Fig. 84.) Diagnosis. — The diagnosis is ex- tremely simple from the persistence of false motion at the point of frac- ture and the complete absence of pain. The skiagraph gives excellent information in regard to the details of the anatomical condition. Prognosis. — The prognosis is doubt- ful, as in a certain number of cases the condition resists the most ener- getic treatment, v. Brims estimates only 56 per cent, of recovery follow- ing resection. Of 1S7 cases of pseudarthrosis of the upper arm, 98 re- covered, 3 were improved, 73 remained unimproved, 5 died. Accord- ing to Midler's more recent statistics of 48 resections of the long bones for pseudarthrosis, there was a positive result in 44 — in 5 of which after secondary operation — and no deaths. Treatment. — In recent cases the milder measures should be first em- ployed; rubbing together of the fragments, massage, injection of irritating fluids — tincture of iodine, 5 per cent, carbolic acid, 4 to 10 per cent, chlo- ride of zinc solution; and if the condition is more that of delayed union, it calls for exact fixation in a strip splint and passive congestion by means of an elastic bandage, as employed by Dumreicher. Further, the surgeon may consider subcutaneous tearing of the intersubstance; electropuncture or thermopuncture; or he may drive ivory pegs into the fragments or nail or screw them together. For the majority of cases the surest method is the removal of the interposed tissue and resection with its various modifications. The fragments should be freshened, not obliquely or transversely as was formerly done, but angularly or zigzag, in order "to obtain better fixation ; or the upper fragment may be freshened and introduced into the split lower fragment. (Berger.) In exposing the Loose fibrous pseudarthrosis of humerus. i v. Bruns. 136 INJURIES OF THE UPPER ARM. fragments and removing the interposed tissue the musculospiral nerve should be carefully avoided. Oilier reports a case in which the interposed Fig. 83. Fig. 84. Nearthrosis of humerus with capsule and growth of cartilage on the fracture surfaces. (Stanley.) Nearthrosis of humerus involved hy arth- ritis deformans with numerous free bodies. (Honridge.) Fig. 85. ^sN tissue contained a splinter two and a half inches long and the musculo- spiral nerve; while dissecting layer by layer with a bistoury a convulsive movement was observed and the nerve, dis- colored by blood-pigment, was recognized with difficulty and isolated. Interposition of the musculospiral may be diagnosticated by pressing the fragments together and eliciting sharp pains radiating to the hand. After freshening the fragments they are united and fixed. For this purpose the vari- ous forms of bone suture may be used (Fig. 85), or the bones screwed together, or pegs inserted. Various methods have been de- vised of inserting ivory pegs or absorbable bone pegs in the medulla (Bircher, v. Brims) (Fig. 86); of driving in pegs of ivory (Figs. 87 and 89), nails, staples (Fig. 88); or of screwing the bones together with iron screws (Bockel); and of fastening the fragments with small metal strips (aluminum, Redard). Recently there has been a more general applica- Bone suture. (After Hennequin and Wille.) PSEUDART1I ni.'sis OF THE JIl-MERUS. 137 tion of transplantation methods, particularly those of J. Wolff, Midler, ami Eiselsberg; a bone-periosteum flap attached to the overlying soft Fig. 86. Ivory peg inserted in the medulla. Fig. 88. Guseenbaiier's staple. I k.. 87. A pseudarthrosis nailed together. Fig. 89. Fragments rabbeted and fastened with ivory pegs. parts is cut out of one fragment, shifted in the long axis to the other, and fastened so that the bone unites as a bridge over the defect. This 138 INJURIES OF THE UPPER ARM. method is generally a minor operation, with the advantages that the fragments do not have to be fully exposed and that there is no essen- tial shortening of the extremity. Scheuer recently secured union of a severe psendarthrosis in a four- year-old boy, whose arm was run over, in a very original manner: after freshening the fracture-ends he implanted a tongue-shaped flap from the thorax containing a piece of the fifth rib. The rib healed in by bony union ; at the end of fourteen days the skin pedicle was divided. Bramann produced a brilliant result in a severe pseudarthrosis of the humerus by transplanting a piece of the patient's tibia measuring 2j x lj.Xj inches. FRACTURES OF THE HUMERUS UNITING WITH DEFORMITY. In spite of the efficacy of present methods of treatment of fractures of the arm, cases are occasionally seen in which either as a result of the indolence of the patient in not giving attention to the fracture or from insufficient treatment the fracture has healed with more or less deformity and consequent functional loss. Naturally this occurs most frequently in compound and double fractures, etc., in which the injuries of the soft parts prevent accurate application of the splint. In young children it is difficult to overcome the displacement because the retention splint rapidly loses its hold upon the parts on account of the shortness of the lever-arm. Most of the pathological museums contain specimens in which either the displaced fragments are united merely by a lateral callus or the angular deformity or overriding of the fragments is. con- siderable. Fractures of the upper part of the arm with angular union, the upper fragment being abducted, the lower parallel to the body, cause functional loss in limiting the elevation of the arm. The callus remains pliable for some time, so that the deformity may be reduced by traction and countertraction with pressure upon the pro- truding angle; under anaesthesia it can be corrected in one sitting and is particularly yielding in the case of rhachitic infraction in young children that so frequently heals with angular deformity. Bardenheuer states that it is often possible to correct old angular fractures by continuous forcible extension. Schreiber states that the same can be accomplished grad- ually with Hessing's sheath apparatus and elastic traction-bands. If bony union is already established, operation is almost unavoidable, and is preferable to mechanical osteoclasis. Subcutaneous or open osteotomy, linear or wedge-shaped, are the typical methods; an increasing angular deformity is an indication preferably for open osteotomy with excision of a wedge. At the present time the .r-ray makes it possible to work out a plan modified for each case in that the skiagram shows where to divide the bone, or whether division is indicated or the removal of a projecting frag- ment or callus is sufficient. The treatment after osteotomy is the same as for simple fracture; in the open operation one should not neglect to secure the advantage of solid fixation obtainable by means of the suture or peg. WOl'M>* OF THE UPPER ARM. L39 WOUNDS OF THE UPPER ARM. Gunshot Injuries of the Upper Arm. -Gunshot injuries of the arm are among the most frequent injuries in war, although the lower extrem- ity is affected somewhat more often. Shot-wounds of the upper arm are sometimes complicated by lesions of the thorax or abdomen. In the Franco-Prussian War, among 32,307 wounds of the upper extremity there were :5041 of the upper arm, and from these 490 deaths. Fischer I cg. 90. Lines of fracture in typical " butterfly" fracture of shaft of long bones. (Bornhaupt, ) gives involvement of the humerus as representing 13 per cent, of the shot injuries of the upper extremity and 35 per cent, of the injuries of the upper arm. In the South African War Matthiolius gives 68 cases of arm involvement in 343 instances of rifle- wound ; among these there were 27 shot-wounds of the soft parts and 41 of the bone; among 25 shot-wounds of the shaft in the upper extremity there were 15 of the humerus; in 81 artillery wounds of the upper extremity there were 9 of the bones, of which 6 were of the humerus. 140 INJURIES OF THE UPPER ARM. Gunshot-wounds of the shaft as produced by modern firearms almost always cause comminuted fracture, while the occurrence of contused and furrow shot-wounds as occasionally produced formerly by the old lead bullets without solution of continuity is doubtful or at least very rare. Round-hole shot-wounds, the usual form in the epiphysis, are excep- tional in the shaft, and are then fissured. Transverse and oblique frac- tures without much splintering are, as a rule, the results of tangential shots. The point-blank shot-wound of the modern small-calibre rifle produces comminution of the shaft at all distance- 1000 to 1500 metres or over), and usually the typical form of " butterfly-fracture." (Fig. 00.) The extent of the zone of splintering was found by Kiittner to be approximately the same at all distances in the humerus (9 to 10 cm.); on the other hand, the size and number of splinters varied greatly. Large and small splinters are produced at all distances, although the large splinters are most numerous at long range, and shattering with numerous small splinters more frequent at short range. Accompanying thi- comminution there are severe laceration of the soft parts and a large wound of exit. In gunshot-wounds of the shaft the projectile or a portion of the same frequently becomes lodged. Wounds of the soft parts vary from simple grazed or furrow wounds to the severest grades of laceration produced by "key-holers" and short-range and artillery shots. In the foregoing, the author has followed chiefly the reports of Kiittner and Matthiolius, which are particularly valuable, as they represent the result of practical experience in recent wars. The numerous and extensive shot experi- ments made by Bruns, Kocher, Coler, Schjerning, Habart, Bircher and others, upon which is built up the scientific knowledge of the action of modern firearms, are beyond the compass of available space. hot-fractures. Pure transverse and oblique fractures heal usually in from three to five weeks; with marked splintering consolidation is often delayed. There may still be false motion after six weeks. Actual pseudarthrosis is apparently rare. Severe destruction of the soft parts may not only prevent primary union, but also compromise the final result by producing cicatricial contractures, adhesion of the cicatrix to the bone, and pro- tracted sensitiveness. Treatment. — The value of modern methods is best shown in the med- ical report of Matthiolius, who gives only 1 case of death among 09 WOUNDS OF THE UPPER ARM. 141 injuries of the arm 68 small-arm, i!l artillery wounds- and in this case, seen on the sixteenth day, there was well-cleveloped sepsis beyond the ;iit* this form by a sort of neuritis of the nerves of the medulla, the nerves being compressed in the unyielding meshes of the hone. He states that it was often necessary to trephine the humerus to remove the foci of chronic inflammation, namely, the remains of an acute inflam- mation. In such cases, to pre- Fig. 92. vent recurrence of the pain, the medulla should be opened freely and cleaned out. Tuberculosis of the Shaft of the Humerus. — Whereas tuberculous foci in the ends of the shaft, in the epiphysis, and, in very extensive disease of the head of the humerus, a diffuse infiltration into the medullary cavity, are of frequent occur- rence, isolated primary tuber- culosis of the shaft, either in the form of small periosteal foci or primary tuberculous osteomyelitis, is rare. The diagnosis is aided by the his- tory, the poor general condi- tion, and the crumbling case- ous character of the pus, but is positive only by demonstra- ting the presence of tubercle bacilli and nodules. Syphilitic Affections of the Humerus. — Syphilitic osteo- chondritis sometimes accom- panies syphilis in the newborn and may cause loosening and separation of the epiphysis. Its interest is chiefly pathologico-anatomical and medico-legal. Gummatous ostitis is not infrequent in the humerus in acquired as well as congenital lues, and is usually combined with lesions elsewhere. If a sequestrum results, surgical interference is necessary. Syphilis of the humerus is important surgically chiefly on account of the spontaneous fracture sometimes resulting from gummatous absorp- tion of the bone. The author has seen such spontaneous fractures many times. Union usually follows the exhibition of potassium iodide, but pseudarthrosis may supervene, as noted by Stromeyer, in spite of specific treatment. Tumors of the Humerus. — Tumors are not unusual in the humerus, and are more frequently situated in the upper part near the epiphysis, less so in the middle and low r er thirds. We distinguish: benign forms — exostoses, chondroma, and cysts; malignant forms — sarcoma, cysto- sarcoma, myxosarcoma, and carcinoma. \ Arrested growth due to osteomyelitis of the upper end of the humerus. (Schreiber.) 250 DISEASES OF THE UPPER ABM. Enchondroma. — Enchondroma is sometimes a local manifestation of multiple chondromata of the skeleton and is usually situated at the upper end; it is more common in youth. It is generally benign, its growth ceasing as a rule with that of the bone. Solitary chondroma and osteoid chondroma of the humerus are sometimes very large, and in the course of years may grow to enormous size, as in a case of Atkinson's, in which the limb at the end of twelve years was 1 metre in circum- ference and weighed 36 T 3 ^ pounds as the effect of the tumor. Myxo- chondromata of the humerus undergoing softening and mucoid degen- eration are to be classified usually among malignant tumors. Exostosis. — Exostosis is rather frequent, especially at the upper end, and may be solitary or multiple, particularly at the epiphysis, and form Fig. 93. Cartilaginous exostosis of the upper end of the humerus, (v. Brims.) knobbed, bulbous, gibbous, or uncinate bony excrescences. There may be typical supracondyloid exostosis on the lower end. The cartilaginous exostosis (Fig. 93), covered with a layer of cartilage, and thus identified as a formation resulting from disturbances in the growth of the inter- mediary cartilage, occurs on the humerus as an excrescence varying from the size of a hazelnut to that of a fist. In regard to the origin of the multiple cartilaginous exostoses apt to appear about the anus in childhood, there is proof of heredity through several generations. Symptoms. — The symptoms of exostosis are the gradual growth of a hard bulbous or gibbous tumor, generally easily felt, and occasionally DISEA SES OF THE II UMER US. 151 considerable functional disturbance, especially limitation of abduction and rotation of the arm. Pressure of the exostosis upon the nerve may produce considerable discomfort. Stanley saw an exostosis at the lower inner part of the arm which produced severe pain in the region supplied by the ulnar, and another which had pierced directly through the ulnar and split it into halves. PROGNOSIS. — Important for the prognosis is the circumstance that in childhood the growth of the exostosis ceases with that of the bone. The axial growth of the upper arm always suffers if the exostosis is large, so that the arm may be much shorter than its mate. Treatment. — As soon as an exostosis occasions much disturbance it should be chiselled off, a simple procedure if it is pedunculated. If it is situated on the anterior surface, the biceps tendon should be guarded, as it may be displaced by the growth; the circumflex nerve is also to be avoided. Exostoses are occasionally seen on the shaft referable to traumatic injury of the periosteum or ossification of the muscle, par- ticularly the brachialis. Thorn-shaped or prickle-shaped excrescences occur on the humerus, in connection with such on many other bones (in the so-called Stachelmenschen). Bone cysts of the humerus are rela- tively benign and are generally softening-cysts. They may be multiple, appearing at different points on the skeleton, as noted by Virchow. Sonnenburg saw a cyst of the humerus in a girl of twelve years result- ing apparently from a fracture received five years previously; there was bulging of the upper third of the humerus; the wall of the cyst was in part very thin, giving "parchment crackling" and containing bloody serum. The entire anterior wall was excised and the cyst excochleated. Aneurism. — Aneurism of the bone should be mentioned at this point. According to the reports found in the literature, its occurrence cannot be denied, although in the majority of instances it certainly should be regarded as a myeloid tumor with profuse hemorrhage; in view of the relatively favorable prognosis of encapsulated myeloid sarcoma, it is not improbable that the tumor would yield to incision and tampon- ing. Echinococcus. — Echinococcus occurs with apparent predilection in the humerus; at least among 33 instances of echinococcus of the bones collected from the literature by Reczey, 7 affected the humerus. The diagnosis is usually certain only after the cyst has ruptured and cysts have been discharged from the medulla, or by exploratory operation. Sarcoma. — Sarcoma is the most frequent malignant tumor of the humerus and is situated usually at the upper end, occasionally in the middle third, and rarely at the lower end. Gross, who states that 70 per cent, of the central tumors of the long bones are sarcomata, in 165 cases of sarcoma of the long bones found 25 of the humerus. In 19 cases of myelogenous sarcoma, Nasse found 3 of the humerus; among 20 periosteal sarcomata he found 5 of the humerus, 4 of which were at the upper end. The growth may be myelogenous or periosteal; the first variety, which is encapsulated, is regarded as relatively benign. In 152 DISEASES OE THE UPPER ARM. general, sarcoma of the humerus is most common between the twenty- fifth and thirty-fifth year and often grows rapidly. Trauma may be an exciting cause, and according to the statistics extant it appears that it applies more to sarcoma of the extremities than to malignant tumors of other parts of the body. In a number of instances the growth ap- peared in the callus of a previous fracture. In 17 cases of callus tumors Haberen collected 8 of the humerus. He saw a laborer, fifty- four years old, w r ho had been run over and received a comminuted fracture at the junction of the upper and middle thirds; it healed with a normal amount of callus; one month later there were severe pains at Fig. 94. Osteochondroma of humerus. (Hull.) the point of fracture; eleven months later there was a tumor the size of a man's head which encompassed the entire periphery at the lower third. It was found on amputation to be a chondrosarcoma with partial mucoid softening, that had replaced the former callus. Symptoms. — The symptoms at first are often merely dull pain and slight functional disturbance, or they may be absent. The rapid appear- ance of swelling or a spindle-shaped growth, increasing in a few months to the size of a fist or head, soon indicates the malignant character of the disease. A dilated network of veins is usually visible beneath the stretched skin; the tumor not infrequently shows points of discoloration DISEASES OF THE HUMERUS. 153 or pulsation due to its great vascularity. Spontaneous fracture is not rare. ( Fig. 95.) Diagnosis. — The diagnosis of beginning sarcoma is often difficult. It may resemble periostitis, osteomyelitis, or tuberculosis, particularly if the tumor is circumscribed, gives false fluctuation or is accom- panied by high or varying temperature, a not infrequent occurrence if the growth is rapid. The cases in which the joint is involved at an early period are especially difficult to diagnosticate. As to the differ- ential diagnosis from joint-affections, in sarcoma the centre of the swelling lies more at the epiphysis than at the joint. An early diagnosis Fig. 95. Sarcoma of the humerus with spontaneous fracture. (Schreiber.) can often be made with the skiagraph. (Fig. 96.) Puncture with a large needle or the lancelet often gives valuable information from the par- ticles of tissue and their histological examination, especially in the case of soft tumors. Prognosis. — The prognosis is favorable only for the lamellated, well-encapsulated myelogenous sarcoma; if curetted out or resected, recovery is sometimes possible. All other forms of sarcoma are char- acterized by great malignancy and rapid invasion of the muscles and veins; they may spread rapidly and diffusely over the shoulder and become inoperable. (Tig. 97.) 154 DISEASES OF THE UPPER ARM. Fig Carcinoma. — Carcinoma of the humerus occurs secondary to carci- noma of the breast or primary carcinoma of other parts — for example, the thyroid, as noted by Eiselsberg. The growth is sometimes ushered in by severe pains; occasionally the first symptom is a sudden fracture. Cases of epithelial car- cinoma starting in old necrosis- fistulas of the humerus are re- ported. Treatment. — The treatment of malignant tumors of the hu- merus is purely operative, and in the majority of instances means amputation. Resection can be considered only for the rare cases of benign, encapsulated giant-cell sarcoma or chondroma of the articular end, of which there are numerous instances reported in the literature. In resecting the upper third of the humerus for sarcoma, Wiesinger made a flap corresponding to the deltoid with base above. Total resection is rarely indicated for tumors of the humerus. In a case of sar- coma developing after repeated fracture of the arm in a woman forty-seven years old, Rotter re- sected the entire humerus and two-thirds of the musculospiral nerve through an incision along the great vessels. Amputation at the shoulder is indicated for the majority of malignant tumors of the humerus. Considering the frequency of local recurrence after exarticulation for sarcoma — which is explained by Nasse by the leaving behind of microscopic portions of infiltrated stumps of muscle — and the unfavorable prog- nosis of interscapulothoracic amputation when done secondarily, Berger recommends that the latter operation be performed at the outset. In agreement with the majority of recent articles the author can only add his approval. In 46 operations of this kind collected by Berger there were only 2 deaths — in 1 the operation could hardly be held responsible — so that Berger assumes a mortality of 5 per cent., whereas the mor- tality attending removal of the shoulder-zone when done secondarily for recurrence is 13 per cent.; in addition, the number of recurrences are Skiagram of a sarcoma of the humerus. ( Fisk DISEASES OF THE HUMERUS. 155 fewer, hence the better prospect of permanent recovery, for in 33 per cent, the recovery lasted for a year or more. Konitzer, who collected the statistics of interscapulothoracic amputation up to 1899, estimates for operations for tumors: immediate recovery, 96 percent.; death at Fig. 97. Sarcoma of the humerus, (v. Bruns.) the time of operation, 4 per cent.; recurrence, 21 per cent.; free from recurrence up to a year, 34 per cent. ; free from recurrence more than a year, 21 per cent.; recovered without report as to later condition, 24 per cent. CHAPTER VII. OPERATIONS OX THE UPPER ARM. LIGATION OF THE BRACHIAL ARTERY. The brachial artery can be ligated in the internal bicipital groove throughout the length of the upper arm. The possibility of anomalies should always be kept in mind; one of the most frequent is the division higher up into two branches, the one following the normal course of the brachial, the other more superficial and separated from it laterally, running with the basilic vein; or the division may be high up and the radial and ulnar arteries lie beneath the skin. Naturally in such cases ligation of one branch would not be sufficient. The arm is abducted and semiflexed; an incision H to 2-j inches long is made through the skin and fascia in the internal bicipital groove, the inner border of the biceps exposed and drawn outward; in the middle of the arm the median nerve lies upon the artery, higher up it lies to the outer side, farther down to the inner side. The artery is accompanied by two veins. Gangrene of the extremity or aneurism above the ligature are rare sequelae. EXPOSURE OF THE NERVES OF THE UPPER ARM. The median nerve may be exposed at any level of the arm at the inner border of the biceps. (Fig. 98, C.) The nerve accompanies the brachial artery, in the upper half lying to the outer side, in the lower half to the inner side and more superficial. The ulnar nerve is best found through a longitudinal incision at the point given in Fig. 98, .1, the breadth of two ringers above the internal epicondyle. It is only necessary to incise the skin and superficial fascia behind the attachment of the intermuscular ligament. The nerve is accompanied by the collateral ulnar artery. The musculospiral nerve, although accessible at various levels, is most frequently exposed at the point where it crosses the outer surface of the humerus, exceptionally higher up on the posterior surface. To find the nerve below the middle of the arm on the outer surface, a two-inch incision is made midway between the external epicondyle (B) and the deltoid insertion (C) in the external bicipital groove. (Fig. 99.) Exposing the tendinous external head of the triceps and separating the muscular fibres of the brachialis, the nerve is felt as a firm cord which can be rolled beneath the fingers. The nerve lies upon the bone; to (156) PARTIAL RESECTION OF THE SHAFT OF THE HUMERUS. 157 its radial or outer side lies the profunda artery, behind it the musculo- cutaneous uerve supplying the radial side of the posterior surface of the forearm. To find the musculospiral nerve above the middle of the arm on the posterior surface, die incision is made at the level of the pos- terior axillary fold in a line drawn upward from the tip of the olecranon at a point a finger's breadth behind the posterior border of the deltoid close to the long head of the triceps. The latter is easily pulled aside Fig. 98. Fig. 99. Incision for the ulnar (-4) and median (C) nerves. (Vogt.) Incision for the musculospiral nerve. (Vogt.) and the incision carried down into the space between the long and outer heads of the triceps, which are separated from each other bluntly down to the bone. The nerve lies between the attachments of the inner and outer heads of the triceps after penetrating the long head of the triceps at the lower border of the latissimus; the profunda artery runs in front. PARTIAL RESECTION OF THE SHAFT OF THE HUMERUS. The path through which the shaft of the humerus is reached easily is shown by an interrupted line corresponding above to the groove between the pectoralis and deltoid, farther down, to the external bicipital groove, and from this point running to the external epicondyle. Due regard for the musculospiral nerve prevents the incision being carried down to the bone in the entire course of the external bicipital groove. On this account Larghi advises an incision in the bicipital groove above or below the musculospiral; the bone is then sawed through and freed 158 OPERA TIOXS OX THE UPPER ABM. from the soft parts as far as desired. He recommends further to make two incisions, one above and one below the point of resection and extraction; to divide the bone at both ends of the piece to be resected without exposing its middle portion, and after it has been made mov- able by the saw-cut to extract it. He calls this the tunnel method. This method is practicable for necrotomy or early resection in acute osteomyelitis, the questionable justification of which latter procedure will not be discussed here. In general the method is to be preferred which allows inspection of the focus in its entire extent before resection. The musculospiral nerve is first partially exposed (see the preceding section) — that is, it is left partially enclosed in the muscles and care- fully retracted. According to the indication, the bone is exposed and sawed off beneath or with its periosteum. To expose the entire shaft, the incision is prolonged in the same line downward to the epicondyle, upward to the insertion of the deltoid, and from this point to the neck of the humerus in the groove between the deltoid and pectoralis. The deltoid is lifted off at its insertion, the circumflex nerve and artery exposed, and the latter tied. The technic of resection of the upper end of the shaft and head is the appropriate combination of the above procedures with the oblique anterior incision employed in resection of the shoulder. AMPUTATION OF THE UPPER ARM. Various incisions, circular, oval, and flap, are used; the one generally preferred is the circular incision in two stages. Kocher especially recommends the oblique incision, namely, an oblique circular incision with its upper end in the internal bicipital groove, so that the cicatrix does not lie under the end of the stump as in the ordinary transverse circu- lar incision. Where the soft parts are diseased or destroyed higher on one side than on the other, the skin-flap incision permits of a longer stump. The skin-flap is usually taken from the anterior surface; v. Brims uses only the skin and the subcutaneous tissue; Kocher, on the contrary, in view of the lateral flattening of the arm, makes the flap on the side. The length of the flap should be the same as the diameter of the arm, the base the width of half the circumference. One can also make a large anterior and a small posterior flap. The arm being removed, the brachial artery and veins should be found and tied in the internal bicipital groove, the profunda and the accompanying vein tied in the external bicipital groove, and the ends of the nerves shortened. The dressing should include the shoulder — spica. The prognosis of amputation of the upper arm as such is absolutely favorable at the present time, the mortality in uncomplicated cases being practically nil. The danger lies solely in local or general compli- cations, especially in existing sepsis. Consequently the mortality of amputation for trauma varies according to the time at which it is per- formed. High amputation, if it is possible, is much to be preferred AMPUTATION OF THE UPPER ARM. 159 to exarticulation at the shoulder, disregarding the severity of t he oper- ation, because of the value of a small stump for holding objects againsl the chest. Prothesis to Replace the Amputated Arm. -The question of com- pensating for the loss of an amputated arm by artificial apparatus is of (rreat practical importance. Such an apparatus should nol only conceal the deformity, but also replace as far as possible the function of the limb, and the surgeon ought to interest himself more in tlii^ matter than has been the case thus far, and not leave it entirely to the limb-maker. The Fig. 100. Fig. 101. Workinj; prothesis. (Le Fort.) Nyrop's working prothesis. longer the stump, the more suitable it is for a prothesis. The position of the scar should have regard for the pressure of the apparatus. There- fore the circular incision is better than a flap incision. The longer the lever-arm, the better the movements of the apparatus can be controlled by the other limb or by the movements of the shoulder or body. For this reason the usefulness of a prothesis decreases with the height of amputation; in amputation of the forearm active flexion and extension of the elbow are retained, and supination and pronation can be utilized for the movements of the fingers. An artificial arm should be simple 160 OPERATIONS ON THE UPPER ARM. in construction, easily applied, and require the least possible repair. It is usually made of sheaths of worked leather, formed after a plaster or wood model, with some sort of artificial hand attached, and is hinged and adjustable at the elbow by means of lateral metal strips. It is also jointed at the shoulder and attached to a shoulder-cap or jacket. In general, if a prothesis is needed on only one side, a substantial artificial arm which can be adjusted by the sound hand for seizing and holding objects, is to be preferred to a complicated apparatus. In the construc- tion of the limb the requirements of the individual case will always be considered and complicated apparatus recommended only for skilled laborers. For most individuals of the working classes the so-called "work-arm" is best. One should strive to obtain solidity, simplicity, cheapness, and durability in the construction, rather than the conceal- ment of the deformity. Rallif, Van Petersen, Dalisch, and others have devised various apparatus, the description of which is hardly necessary here. The accompanying illustrations show the construction of Le Fort's modification of Gripouilleau's apparatus (Fig. 100) and Xyrop's "work- claw" (Fig. 101). It is beyond question that many kinds of work, such as digging, plowing, mowing, threshing, can be done with such apparatus, although the zeal and intelligence of the individual concerned are im- portant factors; particularly where the deformity is bilateral it is aston- ishing how much can be done with such protheses. Fven those with double amputation are able to " hold their own" sometimes in agricul- tural work, such as mowing, loading, etc. (Schreiber.) MALFOKMATIONS, INJURIES, AND DISEASES OF THE ELBOW AND FOREARM. By Pbivat-docent Db. M. WILMS. Anatomy and Mechanism of the Elbow-joint.— The elbow-joint is composed of the articular surface of the cubital process of the humerus, the disk-shaped depression of the head of the radius, and the semilunar incisura of the ulna. The head of the radius articulates on the outer half of the joint with the outer surface of the ulna in the incisura radialis ulna?. The cubital process of the humerus consists of the external con- dyle, whose rounded joint-surface, the capitulum humeri, articulates with the radius, and of the internal condyle, whose joint-surface, the trochlea, is partly surrounded by the incisura semilunaris of the ulna. From each condyle projects a prominent tuberosity, the external and internal epicondyles. The motion of the arm at the elbow-joint is essentially that of a hinge. The trochlea produces, however, a certain amount of screw action in flexion and extension. In this manner, by extension of the arm the normal physiological position of cubitus valgus is produced, the axis of the arm making an outward open angle with the upper arm. In complete extension the olecranon meets a resistance in the fossa on the posterior surface of the humerus. In flexion the coronoid process strikes against the coronoid fossa on the anterior surface of the humerus. In adults the arc from full flexion to full extension is about 150 degrees. Abduction and adduction in the elbow-joint are prevented by the reinforcing ligaments on the inner and outer side of the capsule. Of these, the internal lateral ligament (ligamentum collaterale ulnare) is attached above to the internal condyle and epicondyle, below to the ulna; the external lateral ligament (ligamentum collaterale radiale) is attached above to the external condyle and epicondyle; below, it blends with the annular ligament surrounding the head of the radius, and is thus indirectly attached to the outer side of the ulna. The external lateral ligament (ligamentum annulare radii) permits of the necessarily free rotary movement of pronation and supination of the radius in that it is not connected directly with the radius, the latter with its neck lying between the bands of the ligament like a button in a button-hole. Impairment of free rotation of the head of the radius in the elbow-joint thus hinders pronation and supination of the forearm. The arc of pronation and supination of the hand in the adult is about Vol. III.— 11 ( 161 ) 162 MALFORMATIONS AND DISEASES OF ELBOW AND FOREARM. 150 to 160 degrees. The cheeking of this motion depends essentially upon the degree of tension which exists in the ligaments between the bones of the forearm at their upper and lower articular ends. The contact between the two bones of the forearm as observed upon the cadaver during full pronation and supination does not take place in the living subject. The epiphyseal lines of the humerus and of the bones of the forearm lie within the joint — that is, inside of the capsular attachments — a fact of great importance on account of the frequency of injuries and diseases of the elbow in children. The author will return later to the development of the epiphyses in considering the fractures of the elbow-joint. The lines of attachment of the capsule — that is, the line of demarcation of the joint cavity upon the humerus — are as follows: The epicondyles and adjacent surfaces of the condyles lie outside of the capsule. Between these two points the capsule extends upward on the anterior and posterior surfaces of the humerus to a point in the middle line above the coronoid and olecranon fossas. On the forearm, as already mentioned, the head and neck of the radius lie within the capsule. On the ulna, on the other hand, only the incisura semilunaris and incisure radialis lie within the capsule, the posterior surface of the olecranon being extracapsular. Corresponding to this arrangement of the capsule, intra-articular extravasations and hemorrhages will be most apparent where the capsule approaches the surface — that is, at either side of the olecranon behind, where two elongated swellings are visible in extravasation or inflammatory processes in the joint; also below the internal epicondyle, and especially above the head of the radius below the external epicondyle. In inflammatory affections of the capsule and synovialis a characteristic point of sensitiveness is present, particularly at these two latter points, for here the diseased synovial membrane can be compressed against the underlying bone, the head of the radius. Dur- ing flexion the capsule is thrown into folds upon the anterior surface of the humerus; during extension upon the posterior surface. CHAPTER VIII. DEFECTS OF THE FOREARM AND MALFORMATIONS OF THE ELBOW-JOINT. The gross disturbances in growth and the arrest in development of the arm are only of subordinate interest for the practising surgeon. The disturbances in development known as phocomelus and hemimeles may be due to faulty construction of the ovum or result from constriction produced by amniotic growths and bands. An interesting example of the latter is presented in Fig. 102, defect of the forearm. The hand is recognizable as a rudimentary projection upon the stump. This rudi- ment is movable and is able to seize objects, as shown. Upon the top Fig. 102. Fig. 103. Congenital defect of the forearm and hand due to constriction of amniotic bands. Man aged twenty years. (Trendelenburg.) .Y-ray of Fig. of the stump is seen the cicatrix produced by amniotic adhesions. The proof that such malformations do not arise from defects in construction is shown by the x-ray picture of this malformation (Fig. 103), in which the radius and ulna are normal up to the point of constriction ; both bones appear as if amputated. The only task which concerns the surgeon in such defects is to conceal the deformity and make it useful to the patient by some mechanical apparatus. As mention will be made later of the more important points concerning such apparatus in considering the hand, it will be sufficient to indicate here that the present tendency is to do away with very compli- cated contrivances and use only the more simple and durable apparatus. I 163) 164 MALFORMATIONS OF THE ELBOW-JOIST. Fig. 104. In regard to the special forms of anomalies in development, it is suffi- cient to note the fact that rare cases of congenital dislocation of both bones of the forearm, both backward and forward, have been seen. Congenital dislocations of the radius have been more frequently reported. Ronnenberg collected 31 cases of this sort in part of which there was a certain heredity. In several cases the affection involved both arms; partial development of the radial articulation of the humerus and of the head of the radius and the even more frequent absence of the articular cartilage indicate a disturbance early in em- bryonal life. The head of the radius is usually dislocated backward. The movements of the arm are only slightly impaired. The radius is usually longer than the ulna. The most practical operative measure in connection with congenital dislocations of the head of the radius is resection of the capitulum radii, which will be discussed later under acquired dislocations. The relatively slight functional disturbance makes it necessary only in a few cases. Cubitus varus and valgus are the terms applied, according to the analogy of the disturbances in the development of the knee-joint, to the conditions in which the axis of the forearm di- verges more or less from the prolongation of the axis of the upper arm. Cubitus varus and valgus occur congenitally, and are occasioned by a relaxed condition of the articular liga- ments, by extension and especially by hyper- extension; it is frequently possible for a partial dislocation to be produced. In these cases heredity plays an important part. Cubitus valgus and varus may arise in the course of post-natal growth from premature os- sification of one or the other of the upper epi- physeal lines of the bones of the forearm pro- ducing an inequality in the length of the two bones and a consequent abnormal attitude of the forearm. The normal so-called physiological cubitus valgus as described by Mikulicz is an impor- tant consideration in the analysis of these anom- alies. According to Htibscher's investigations, this physiological cubitus valgus is less frequent in men than in women. Taking the angle a (Fior. 104) made by the axis of the forearm and the prolongation of the axis of the upper arm, the so-called complementary angle, as the standard of measurement, the physiological cubitus valgus shows an average variation in men of from 1 to 9 degrees; in women, of from 15 to 25 degrees. Hubseher discovered that this physiological increase of valgus position took place not in childhood, but after puberty. The reason for this deviation is not to be found in the elbow-joint itself, but rather in the outward deflection Physiological cubitus valgus in female, a = 20 degree*, the complementary angle. MALFORMATIONS OF THE ELBOW-JOIST. 1G5 of the lower third of the diaphysis of the humerus. This is character- istic for the female forearm, in that the arm is forced into this position by the narrowness of the shoulders as compared with the breadth of the pelvis. Traumatic cubitus varus and valgus will be considered under frac- tures of the elbow-joint. It should be mentioned here, however, that cubitus valgus may result from injury to the epiphyseal line of the humerus and the consequent disturbance in growth. More frequently, however, it follows a supracondyloid fracture (fractura supracondylica) or fracture of the external condyle. Cubitus varus may result from malunion of a fracture of the internal condyle. Slight cubitus valgus and varus do not require operative treatment. The more severe forms may be corrected by a wedge-shaped resection in the lower third of the shaft of the humerus. The chief task is natu- rally to prevent deformity by securing proper union of the fracture. CHAPTEK IX. INJURIES OF THE ELBOW-JOINT. CONTUSION OF THE ELBOW-JOINT. Contusion of the elbow-joint results from direct violence upon the region of the joint, and, disregarding the lesions of the soft parts, pro- duces lesser injuries of the exposed bony parts, the olecranon, condyles, and epicondyles. It may be difficult under circumstances to exclude with certainty the existence of slight fissures in the bone. As the x-ray investigation has taught, they occur much more frequently than was formerly believed. The movements of the joint are slightly painful, but not limited. Extravasation of the blood in the joint is usually slight. Diagnosis. — It is a safe rule to make the diagnosis of contusion only after the most careful examination of the bone has excluded the possi- bility of fracture or fissure. The swelling of the joint due to hsemar- throsis is often concealed by periarticular swelling of the soft parts, nevertheless an intra-articular effusion of serum or blood is recogniz- able, corresponding to the normal contour of the capsule, at both sides of the olecranon, upon the posterior surface of the condyles and above the head of the radius. Treatment. — The treatment of contusion consists in rest for several days, according to the severity of the injury. Wet dressings and press- ure, elevating the elbow upon a pillow, and applying an ice-bag or hot- water bag check the swelling and diminish pain. Care should always be exercised that the ice-bag or hot-water bag does not come in contact with the skin, as gangrene or serious burns may result. SPRAINS OF THE ELBOW- JOINT. By sprain is meant an injury of the capsule and of the ligaments, produced by forced movements, either hyperextension, ulnar adduction, radial abduction, or violent pronation and supination. Hyperextension often produces a backward dislocation of the forearm (luxatio anti- brachii). This backward luxation, however, may not be complete, but instead the hyperextension may produce merely laceration of the anterior wall of the capsule, and finally laceration of the lateral ligaments with- out displacement of the joint-surfaces. This form of laceration of the capsule and ligaments is the one most frequently observed. Some of the forms of sprain have the same etiology as backward dislocation. Swelling of the soft parts occurs at the points corresponding to the lesions of the capsule and ligaments, and if diffuse involves the entire ( 166) FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 167 region of the joint. Intraarticular hemorrhage often increases the swelling. In the case of a simple sprain the movements of the joint are only slightly impaired. Extension of the forearm is painful from the tension upon the injured anterior wall of the capsule. Abnormal mobility rarely occurs in sprains about the elbow-joint, in contrast to those of the knee-joint, in which, as the result of laceration of the lateral ligaments, genu varum or valgum is easily produced. Diagnosis. — The diagnosis of sprain is to be made only if, after careful examination, every lesion of the bones can be excluded. Slight bone injuries, such as avulsion of the coronoid process of the ulna or of the epicondyles, are easily concealed by marked swelling of the soft parts. It is here that examination with the x-ray is particularly valuable; in fact, is more valuable for the elbow-joint than any other articulation. The amount of swelling and ecchymosis is not conclusive for the diag- nosis, as they vary greatly. Swelling due to laceration of the muscles and tendons in the region of the elbow-joint may make the diagnosis difficult. For the differential diagnosis of sprain from intra-articular fracture, careful palpation and determination of the bony parts are important; secondarily the slight functional disturbance verified by executing slow movements of the arm. Prognosis. — The prognosis of sprain with extensive laceration of the capsule and the ligaments is frequently a doubtful one. For although abnormal looseness of the joint may persist in a few cases, more fre- quently stiffness is apt to follow simple sprain in consequence of intra- articular adhesions and cicatricial induration of the capsule, ligaments, and surrounding soft parts, especially in old individuals. Treatment. — In the treatment of recent injuries of the elbow-joint, particularly in children, it is advisable in the presence of marked swelling to make a thorough examination under anaesthesia. Every bony promi- nence should be palpated systematically and the results compared with the normal relations in the sound arm, and if necessary with an anatom- ical specimen. In the average case, rest for about eight days is advisable. During this time light massage, later combined with warm baths, aids resorption of the extravasation. At the end of eight days gentle move- ments, gradually increased until full motion is obtained in the third or fourth week. It is important to continue this after-treatment for some time to prevent secondary shrinkage and contractures, as the latter may develop at a late period. FRACTURES OF THE ENDS OF THE BONES FORMING THE ELBOW-JOINT. Fractures at the Elbow-joint. Diagnostic Examination. — The complicated anatomical and mechan- ical relations of the elbow-joint present many difficulties in the diagnosis of bone fractures involving this joint. In every injury of the elbow-joint 168 INJURIES OF THE ELBOW-JOINT. suspicious of fracture, the examination should be made in a somewhat typical manner, applicable generally to the individual fractures to be described later on, as follows: The upper part of the body is stripped in order to compare the sound with the injured arm. The surgeon obtains by inspection the relation of the forearm to the upper arm, the presence of any shortening of the forearm, the position of the hand. Further, the posture of the body, and the way in which the injured arm is supported by the sound one, is of interest. Also the presence of swelling, the anteroposterior and trans- verse diameters of the joint, visible contusions, ecchymosis, wounds, and finally the subjective pain at the time of the accident and afterward. After obtaining the history and inspecting the limbs, palpation is necessary to determine the position of certain fixed points. It is advis- able first to acquaint one's self with the position of these fixed points on the sound arm. Palpation of the elbow-joint in the absence of swelling of the soft parts gives four bony points; three of these (the olecranon, internal epicondyle, and external epicondyle) lie in a straight line with the arm extended; with the arm flexed they form the three points of the triangle seen in Fig. 105. The normal position of these three points upon the sound Fig. 105. Line joining: the epicondylea and olecranon process, with the arm extended (a) and flexed (6). arm should be referred to constantly for comparison. The fourth point, the head of the radius, is palpable from T 3 ¥ to -f of an inch below — that is, toward the hand from the external epicondyle — if pronation and supination of the forearm are possible and not too painful. By rotating the hand one can feel the head of the radius revolving beneath the fingers. Having ascertained the position of the above fixed points, and the existence of any change of relation between them, the surgeon examines for points of tenderness and crepitus, the limits of active and passive motion of the joint — that is, normal extension, flexion, prona- tion and supination — finally, abnormal hyperextension or lateral adduc- tion and abduction. In adults all these data may be obtained in cases of slight injury of the elbow-joint without the aid of narcosis, by carrying out careful movements of the arm. As a rule anaesthesia is necessary to make an FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 169 accurate diagnosis, as a complete examination of the mobility, especially abnormal mobility, is impossible on account of the pain. In children, who constitute the greater contingent with reference to the injuries of the elbow-joint in question, narcosis is necessary and advisable in almost all cases. In children, furthermore, not only is the examination hin- dered by the restlessness of the patient, but the smallness of the bones and the often marked swelling also make diagnosis rather difficult. The surgeon should not be satisfied with a superficial examination in children if the examination is not easy, as the elbow-joint in all cases demands an accurate diagnosis, since the treatment can and must vary considerably according to the form of the fracture. A certain classifica- tion for the better understanding of the individual forms of the frac- tures of the ends of the bones forming the joint is of advantage. The surgeon must remember, however, that the fracture-lines given here vary considerably and are capable of many combinations. Fractures of the Lower End of the Humerus. Surgeons distinguish the following fractures of the low T er end of the humerus, to be considered in order: 1. Fractura supracondylica (supracondyloid fracture). 2. Fractura supracondylica with longitudinal fracture betw r een the condyles, T- or Y-shaped fracture. „ . ,. f externalis. 3. Fractura condyh | lateraUg 4. Fractura epicondyli lateralis. _ ^, . i ,- f internalis. 5. b ractura epicondyli < r r 1 J { medians. 6. Fractura condyli medialis. 7. Fractura diacondylica. 8. Fractura capituli humeri. Supracondyloid Fracture of the Humerus. — The fracture-line lies, as the name indicates, above the condyles and epicondyles in the lower end of the shaft. In the simple form the fracture-line lies en- tirely without the joint-capsule. The fracture is seldom transverse, as shown in the a;-ray picture. (Fig. 10G.) Usually it is oblique, as a posterior fragment of the lower end of the diaphysis generally breaks off with the processus cubitalis. In this way the line of fracture is higher behind than in front. In Fig. 107 the .r-ray shows the usual line as it exists in several typical pictures in the author's possession. Cause and Mechanism of Origin. — The fracture is usually produced by hyperextension of the elbow-joint from a fall upon the surface of the outstretched hand, the arm being abducted. In this manner the joint-capsule is drawn tightly over the anterior surface of the lower end of the humerus and snaps off the articular portion backward. Fracture can only occur when the capsule, as in young children, has a greater power of resistance than the bone and therefore cannot be torn. If the anterior portion of the capsule tears because the bone has the greater 170 INJURIES OF THE ELBOW-JOINT. power of resistance, as is usually the case in older children, a posterior dislocation occurs as a result of hyperextension. Supracondvloid frac- tures in early childhood and the backward dislocation frequently seen from the tenth to the fifteenth year are therefore etiologically closely related. The supracondyloid fracture, however, is not confined to children, as it can be produced in adults by different forms of trauma, such as machinery accidents, fly-wheel injuries, by hyperextension and rotation. The same action as produced by a fall upon the hand with the arm extended or slightly flexed may be effected by a blow or push upon the Fig. 106. Fig. 107. Supracondyloid fracture of the humerus, rare transverse fracture. Supracondyloid fracture of the humerus, usual form. posterior surface of the humerus with the forearm fixed. The humerus is thus driven forward. The fracture-line is usually the same as seen in Fig. 107. A second but less frequent form of fractura supracondylica is described by Kocher as "fracture by flexion." It is explained by the normal position of the processus cubitalis of the humerus, which, it will be remembered, is bent slightly forward. A direct blow or push upon the posterior surface of the ulna transmitted to the process in the long axis of the humerus would drive the process forward. In contrast to the first and more frequent form, the fracture-line is oblique in the opposite direction, so that it lies higher upon the anterior surface than on the posterior. (Fig. 108.) FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. IJ\ These types of fracture, whose etiology is essential for a knowledge of such fractures, are not only of theoretical interest, hut also determine, according to the direction of the fracture-line, both the symptomatology and the treatment. For example, in the first case, in fracture by hyper- extension (Fig. 107), the lower fragment is easily pushed backward, while in fracture by flexion (Fig. 108) such a displacement is impossible. The danger of damage to the soft parts about the elbow is greater in the first than in the second type of fracture because the upper fragment may easily perforate forward. Symptoms. — In the common form of fractura supracondylica the forearm and lower fragment of the humerus are usually forced back- ward; the upper fragment projects forward and presses against the soft parts in front of the elbow. On inspection of the injured arm from the side, if a typical displacement of the fragments exists, one observes an angular deviation in the axis of the upper arm above the elbow, which Fig. 108. Fig. 109. Supraeondyloid fracture (flexion fracture). The inflexion in the axis of the humerus in the usual form of supraeondyloid fracture. may be concealed in recent injuries by swelling, ecchymosis, and extrav- asation. The upper arm forms an obtuse angle opening backward, as indicated diagrammatic-ally in Fig.^109. With this displacement of the lower fragment the contour of the posterior surface of the upper arm above the joint is concave backward, like the deformity in backward dislocation of the forearm. By the examination the position of the fixed bony points is determined; the olecranon, external and internal epicondyles, and the head of the radius are in their normal position. By accurate palpation frac- ture tenderness is obtained above the joint, not at the prominent points mentioned. In the crease of the elbow one often feels the sharp edge of the upper fragment of the humerus pressing against the soft parts. The mobility, best determined under anaesthesia, especially in children, is conclusive for the diagnosis of fracture, particularly in contrast to dislocation. The angular deformity of the upper arm and displacement 172 INJURIES OF THE ELBOW-JOIST. are easily overcome by traction upon the forearm. Under certain cir- cumstances they may as easily return. This is diagnostic for fracture against dislocation. Manipulation usually elicits crepitus. Flexion of the elbow-joint is considerably limited if there is forward displacement of the upper fragment, as in flexion the bones of the forearm press against the projecting upper fragment. Under narcosis, on the other hand, hyperexiension is easy. Abnormal lateral movements, abduc- tion and adduction, are possible, and thus the production of a cubitus valgus and varus. Rotation of the hand is not necessarily impaired. The hand is usually supinated by the biceps, the supinator of the fore- arm when the same is flexed, in order to relax as far as possible the tension produced by the projecting upper fragment. The other hand usually supports the affected arm in a characteristic manner to prevent motion and pain. The elbow-joint of the affected arm is usually bent at an obtuse angle. Diagnosis. — From the above symptoms the diagnosis of supracondy- loid fracture is usually not difficult, particularly when aided by an examination under anaesthesia. The fracture is not necessarily accom- panied by any displacement of the lower fragment such as is indicated in the .r-ray picture. (Fig. 107.) A serrated transverse fracture may prevent any displacement of the fragments. In this case, however, the false mobility of the lower end of the humerus is easily demonstrable. There can be no likelihood therefore of confusing the condition with disloca- tion of the elbow in either case. Grasping the epicondyles between the thumb and first finger, and the humerus above with the other hand, false motion is easily obtainable and one can feel the shifting of the lower fragment, accompanied usually by crepitus. In supracondyloid fracture by direct violence the vessels and nerves of the elbow region may be involved. The author mentions here particularly the not very infrequent injury of the cubital artery and median nerve at the elbow by the projecting upper fragment. Under certain circumstances the fragment may perforate the soft parts and produce a compound frac- ture. Perforation of the ends of the fragments upon the posterior surface is relatively infrequent, and is possible only in fracture by flexion, in which the upper fragment may perforate downward and backward. The symptoms of fracture by flexion are the same as those of supra- condyloid fracture, except for the absence of backward displacement of the lower fragment. Treatment. — The great variation in the direction and the numerous combinations of the lines of fracture about the elbow-joint preclude the possibility of a uniform method of treatment for all fractures. This circumstance and the complicated structure of the elbow-joint are often the cause of severe disturbances, which demand as the first essential of treatment that the direction of the fracture should be carefully taken into consideration. It is necessary therefore to describe in connection with every form of fracture the corresponding best method of treatment, in spite of the slight repetitions thereby involved. The diagnostic possibilities presented in the methods of examination by means of FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 173 the cathodic currents demonstrating the presence of injuries and tears so small as to escape detection in the ordinary examination, will cer- tainly present a field for the operative treatment of .fractures barely touched upon at the present time. As mentioned, supracondyloid fracture in the average case pre- sents a typical backward displacement of the lower fragment. To reduce this displacement under an anaesthetic, if necessary by direct pressure and traction, and to adapt the fragments in the best possible position, is the surgeon's first task; retention in the normal position is the chief purpose of the splint. The splint commonly used for frac- ture of the elbow is the circular or two-strip plaster-of-Paris splint, with the forearm semiflexed. The choice of the splint to be used, however, will be determined by the peculiarities of each fracture. The extension splint is being more and more applied to fractures of the elbow. The circular plaster splint has the disadvantage of producing constric- Fig. 110. Fig. 111. Beely's plaster-of-Paris strip splint. tion and even pressure-necrosis or gangrene in the event of post- traumatic swelling or, if applied upon a swollen arm, of allowing second- ary displacement of the fragments after the swelling has subsided. For this reason the two-strip splint is best adapted for general use, as it may be modified and even combined with extension. The most practical forms are those described by Beely and Stimson. (Figs. 110, 111, 112.) Splints may be made of strips of wood or moulded papier-mache bound on with gauze or starch bandages, but these are all inferior to the moulded plaster splint. Kramer's wire splints are often useful in an emergency; also the right-angled tin-gutter splints. Post-traumatic swelling demands particular care in fractures about the elbow-joint. If the patient is not under constant observation, as, for example, in a hospital, the dressing should be inspected at least during the first twenty-four hours to prevent circulatory disturbance, 174 INJURIES OF THE ELBOW-JOINT. especially in children. The parents or relatives should always be warned of the danger of constriction, and should be on the lookout for cyanosis and coldness in the fingers, numbness, or severe pain. The first dressing should not be left on as a rule more than eight days, namely, till the swelling has subsided. The dressing should then be replaced by one fitting more snugly, after the fragments have been carefully adjusted. All splints should be removed not later than the third week. In the case of children they may often be removed sooner. The arm should Fig. 112. Stimson's plaeter-of-Paris splints. then remain free or be bandaged only at night. Following the removal of the splint, daily massage, warm baths, active and passive motion should be instituted in order to overcome at the earliest moment the resulting stiffness of the joints and fingers. For the elbow-joint particularly it is important to remove the splint at the earliest possible moment; the minimum time of fixation, as empha- sized by Kocher, gives the best results. If in three weeks the normal position is not obtained, fixation is of no further avail. FRACTURES OF ENDS OF BONES FORMING ELBOW JOINT. 175 Semiflexion is the rule in fixation for fractures of the elbow-joint to obtain the best union as well as to avoid the compromising effects of ankylosis in the position of extension. The uselessness of an arm ankylosed in extension, if once seen, is never forgotten. The value of the semiflexed position for fixation of supracondyloid fractures is demonstrated beyond question by the x-ray. Smith, from the results of his experience, recommends fixation in sharp flexion in order to overcome the tendency of the short lower fragment to tilt backward. With proper coaptation of the fragments the results of treatment of supracondyloid fractures are usually good, except where the joint is involved. The resulting stiffness in the joint often persists for months, especially in old individuals, in spite of daily exercise. The results are very different if the displacement is not corrected or occurs secondarily in the splint. The persistence of a deformity such as occurs in the common form (Fig. 107) may produce very great limi- tation of motion. If flexed, the forearm strikes against the projecting upper fragment of the humerus. Flexion is thus impossible beyond a right angle. Extension is limited by the tension of the biceps over the projecting edge of the fragment as well as by the large callus resulting from the displacement. The importance of reducing the displacement can therefore hardly be overestimated. Fig. 113. Bardenheuer's extension apparatus for supracondyloid fracture of humerus. ( Griissner. ) Treatment by extension has been recommended especially in the case of children, whose round short arms give so little purchase to prevent displacement within the splint. (Fig. 113.) Various view r s are still held in regard to the proper position of the forearm in an extension splint. No rule, however, is possible. The position should vary with the requirements of the individual case. After manipulation and traction have secured the best coaptation, particularly with the aid of the a>ray, Kocher recommends that the arm should be left free, and emphasizes further that it is important that the lateral 176 INJURIES OF THE ELBOW-JOIST. traction upon the forearm should be exerted outward and upward to prevent lateral displacement of the arm — that is, ulnar adduction — which is easily produced by its own weight. The advantage of extension combined with the recumbent position is the possibility of obtaining exact coaptation of the fragments. (Fig. 114.) How far swelling of the soft parts, oedema about the joint, and, as in- dicated by Bardenheuer, the formation of callus, are influenced favorably by extension, cannot be determined. Production of bone confined to normal limits depends apparently upon the favorable position of the fragments. The form of extension splint mentioned is not applicable to ambulant cases. The ambulant treatment of fractures of the elbow should be avoided, if possible, especially in the case of children and old individuals, Fig. 114. Extension treatment of supracondyloid fracture. on account of the marked swelling in the dependent arm and the possi- bility of inflammatory oedema. Bardenheuer's method of applying an adjustable extension splint can be used if desired. In the less common form of so-called flexion fracture the dislocation is usually slight, and is corrected by the simple plaster splint. Prognosis. — The prognosis of supracondyloid fracture with the proper treatment is favorable. On the other hand, if the deformity is not corrected, motion mav be verv greatlv limited, namelv, to 20 or 30 degrees. If the surgeon has to deal with cases of stiffness and limited motion resulting from improper treatment, passive motion should be first tried. Correction of the position, however, in such cases is usually impossible, even by secondary operation. The position may be improved by a FRACTURES OF FSDS OF BOXES FORM I St; ELBOW JOINT. 177 wedge-shaped excision, but the disturbance produced by the upper frag- ment projecting against the elbow will be overcome with difficulty. Partial removal of the projecting edge through a longitudinal incision may effect slight improvement. Supracondyloid Fracture of the Humerus with Longitudinal Frac- ture between the Condyles (T- and Y-shaped Fractures). -There are many varieties of this form of fracture. The fracture-line may be a combination of fracture of the outer and inner condyles, or of the supra- condyloid fracture with longitudinal fracture, T- or Y-shaped between the condyles. (Figs. 115 and 116.) The variableness and complex form of the fracture-lines are usually the result of direct violence. These fractures occur more frequently in adults than in children from the fact that external violence, such as blows, falls from a great height upon the elbow, contusion and street accidents, is the determining factor. No predisposition is necessary; the external violence is decisive. Fig. 115. T-fracture of the lower end of the humerus. Y-fraeture of tne condyles, (v. Bruns.) Etiology and Mechanism. — Yladelung, from experimental studies, con- cluded that the T-fracture was produced by external violence driving the olecranon like a wedge into the humerus, thereby cleaving the lower end of the humerus. Experiments made by Marcuse disprove this action, as he produced a Y-shaped fracture by a blow upon the lower end of the humerus even after resecting the olecranon. Kocher believes that it is a combination of two fractures. Violence acting upon the lower end of the humerus, as will be seen later, is more liable to fracture the external condyle. The continuation of the same force acting upon the internal condyle alone breaks the latter and completes this form of fracture. The possibility cannot be excluded of a wedge action of the shaft of the humerus producing the cleavage of the condyles. (Gurlt.) At any rate, it almost always forces acting directly upon the elbow-joint, Vol. Ill— 12 178 INJURIES OF THE ELBOW- JOINT. or a fall upon the elbow-joint from a great height, that immediately affects the lower end of the humerus, which give rise to the various forms of T-fracture. The fragments, after being broken off, are still further displaced by the force, so that the humerus is driven between the frag- ments and increases the separation. Symptoms. — The T-fracture has several symptoms in common with supracondyloid fracture. The swelling, pain, and loss of function in the joint are more pronounced, however, as the fracture-line involves the joint. The surgeon notes the amount of swelling and the position of the arm, points of tenderness on pressure, and the pain produced by abduction, adduction, flexion and extension, and jarring. Under an anaesthetic accurate palpation and motion will usually demonstrate crepitus, and in contrast to the marked loss of function observed in active motion as a result of the pain, abnormal mobility, especially adduction and abduction, as well as the possibility of hyperextension, are evident. From these symptoms alone, however, the only possibility would be supracondyloid fracture. In order further to determine the fracture-line between the condyles, it is necessary to ascertain the intermobility of the latter. Seizing the epicondyles between the thumb and first finger it is often possible to move the condyles upon each other. If the con- dyles are separated, they will converge under pressure. Palpation will demonstrate the abnormal width of the cubital process. Pressing the condyles together also elicits pain, a symptom absent in supracondyloid fracture. Diagnosis. — Jn spite of the complexity of the fracture-line and the frequent multiplicity of the fragments a methodical examination will eventually permit of an exact diagnosis. As T- and Y-shaped fractures are usually produced only by marked violence, backward or forward displacement of the upper end of the humerus and a resulting cubitus valgus or varus are not infrequent. Treatment. — Treatment aims to overcome the displacement and reduce the fragments to their normal relation by pressure. In severe fractures an exact reposition of the joint-surfaces is important, a task that is often not easy to accomplish. In these cases the .r-ray is an indispensable aid during the manipulation. The reduction should be done under anaes- thesia. One great difficulty in the treatment is to hold the various fragments in their proper position. The importance of exact coaptation of the fragments for the function of the joint and of prevention of compromis- ing callus for the prognosis is self-evident. Many views are still held in regard to the treatment of T-fractures. The simplest and most practical methods are here, as in the case of supracondyloid fractures, fixation by means of a plaster strip or circular splint, etc. For fractures with marked displacement of the fragments, it is a good plan to apply a circular splint for about ten or fourteen days. During its application the fragments maybe held in position by traction by means of flannel strips incorporated in the dressing. At the end of i. c < < FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 179 fourteen days a two-strip plaster splint may be applied and removed at intervals for massage and gentle passive motion. All fixation splints should be left off of the elbow-joint after the third week. Recently extension splints have met with more general use. Their advantage is unquestionable, but in very serious fractures of the joint they do not prevent the unfortunate results of joint-stiffness. Their superiority, however, is cited by many authorities, among them Konig, Kocher, Stimson, and others. Lauenstein has recently indicated the advantage of extension with the arm extended instead of flexed, to prevent union with abnormal adduction or abduction of the forearm. The possibility of the joint becoming ankylosed in extension demands the removal of the splint at the end of eight or ten days, and gradual flexion of the forearm to a position of semiflexion or acute flexion. This circumstance therefore makes the method objectionable except for very severe cases. The application of the extension splint with the arm in semiflexion is done in the same manner as for supracondyloid fractures. (See Fig. 114.) As a rule neither the extension nor the common plaster splint should be left on longer than three weeks. At the end of this time the existence or the possibility of joint-stiffness requires massage, baths, and passive motion in order to break up the adhesions, prevent further shrinkage of the ligaments and capsule, and, if possible, to check and smooth off any callus formation. The fact that the intra-articular fracture-lines of T- or Y-shaped frac- tures of the humerus make the prognosis much less favorable than in the case of the simple supracondyloid type has been provocation for the attempt to improve the chances of recovery by operative interference. Kocher has published the results of his numerous attempts in this direction. Resection of the two fractured condyles produced an unfavorable result in leaving a flabby and relatively powerless joint. On this account he attempted later, in cases of isolated fracture of the external condyle, to avoid any essential injury by limiting resection to the external condyle. In this manner growth of callus in the joint is most easily prevented and healing simplified to a certain extent. The solidity and mobility of the joint are not altered, as the trochlea suffices for flexion and extension, and pronation and supination are effected in the joint between the radius and ulna. The external condyle is reached through an external longitudinal incision, and is removed without diffi- culty; at the same time the position of the other fragments is determined. Such interference is certainly justified by the generally unfavorable prognosis of T-fractures. In the larger number of cases, however, the question of operation arises usually at a late period, after massage and exercise have failed to overcome severe and persistent loss of function. The nature of the operation will be determined in each case by the nature of the functional disturbance and of the fracture-lines. Callus formations situated in the fossa supratrochlearis posterior and prevent- ing full extension, or in the fossa supratrochlearis anterior compromising flexion, may be chiselled off with good results. Malposition of the 180 INJURIES OF THE ELBOW- JOINT. external or internal condyle with deviation of the forearm in abduction or adduction may be corrected finally by wedge-shaped resection of the shaft of the humerus. The operative treatment of complete ankylosis of the elbow-joint following fractures is a difficult question. Total resection always presents the possibility of a flabby joint, and the latter is generally less useful to the patient than one that is ankylosed. The technic of complete resection is described in the section on Resec- tion of the Elbow-joint. Recently, Wolff recommended the so-called operation of arthrolysis — separation, chiselling away, and removal of all bony or fibrous bands, bridges, or deposits without resection of the entire articular surface — and testifies to the good results. Eiselsberg opened the ankylosed joint through two lateral incisions and obtained partial restoration of the mobility. The procedure is the same as that which he employed for reposition of old dislocations. (See under Dis- location of the Forearm.) T- and Y-fracture. — No fractures of the elbow-joint are complicated by injuries of the soft parts so frequently as T- and Y-fractures. As a result of the severe external violence which is the common cause of these fractures, the most diverse lesions of the skin and soft parts occur, in part as a direct result of the trauma, partly from perforation of the fracture ends, usually the upper one, through the soft parts, either behind through the triceps or more frequently in front through the biceps, or at the inner or outer side of the arm. In the perforating fractures the danger of complications, especially of inflammation and suppuration, is not as great as in severe comminuted fractures produced by direct external violence, and accompanied often with extensive contusion and laceration of the soft parts. Treatment. — The treatment of fracture with perforation of the skin by the ends of the fragments consists in careful disinfection of the skin- wound and excision of its edges. If the skin, soft parts, and projecting bone are soiled, the unclean pieces of bone should be removed and the wound cleaned up thoroughly by excision of all damaged fascia and muscle. Irrigation with antiseptic solutions is not as effectual as the careful removal with scalpel and scissors of all soiled parts. The fracture ends are replaced only after thorough cleansing and if necessary, resec- tion. The importance of free drainage of such wounds is self-evident. In the event of inflammation extending to the elbow-joint, the same must be opened and drained either through the wound or through a counteropening on the posterior surface at the side of the olecranon. The most important subcutaneous injuries of the soft parts resulting not infrequently from T- or comminuted fractures are the lesions of the nerves and the cubital artery. Injury of the cubital artery and the median nerve lying to the inner side of the artery is frequently observed as a result of the usual dislocation forward of the upper frag- ment of the humerus. Regarding the details of the disturbances result- ing from injury to the nerve and vessel, the reader is referred to the section on Injuries of the Soft Parts of the Elbow. FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 181 Fracture of the External Condyle of the Hunerus.— Fracture or avulsion of the external condyle is relatively frequent. Mechanism and Cause. — The mechanism and the cause may vary greatly. A force acting upon the lower end of the humerus and upon the externa] condyle alone may fracture the latter. Usually the break results from a fall upon the hand with the arm extended or slightly flexed, or by a fall upon the elbow itself. By falling upon the hand the force is transmitted chiefly through the radius to the adjacent external condyle and eminentia capitata, thereby pressing off the condyle. It may also he broken off, as Kocher demonstrated, by a blow upon the olecranon in falling upon the abducted arm, the olecranon being driven against the outer condyle. A direct blow against the lower articular surface of the humerus may result also in separation of the external condyle alone, according to Kocher's experiments, for the reason that the external condyle breaks more easily than the internal. Fig. 117. Fig. 118. Lines of fracture of the external condyle. (Stimson.) Fracture of the external condyle. (Child a^ed 5 years. ) Corresponding to these differences in the mechanism the fracture-line is variable, even though slightly so. A small part of the trochlea is often broken off with the eminentia capitata. The fracture-line extends upward above the external epicondyle. The fracture occurs most fre- quently in children. Fig. 118 shows an a>ray picture of such a fracture in a child of five years. The capitulum humeri, in which the primary centre is developing, is broken off with a piece of the lower end of the shaft. Between these two displaced shadows lies the normal line of the epiphysis. Symptoms. — The deformity of fracture of the external condyle may be very slight in the absence of displacement. Motion in the joint is often only slightly disturbed, so that only extreme flexion and extension 182 INJURIES OF THE ELBOW-JOINT. are painful. The involvement of the elbow-joint is denoted only by swell- ing in the region of the outer condyle and by intra-articular hemorrhage. By direct palpation of the elbow one obtains pain by compressing the con- dyle, mobility of the outer condyle, and occasionally crepitus. An impor- tant symptom for the differential diagnosis is demonstrated by abducting and adducting the extended arm. By the tearing off of the outer condyle the radius is no longer held by the external lateral ligament (ligamentum collaterale radiale), so that the forearm can be abnormally adducted. Normally with respect to the upper arm the forearm is in a position of slight cubitus valgus. By avulsion of the external condyle the fixation effected by the external ligament is lost. The radius, external lateral liga- ment (ligamentum collaterale), and condyle being no longer held in position, the forearm can be adducted to a cubitus varus position. Press- ing the forearm against the humerus in abduction is especially painful, as the head of the radius is thus pushed against the displaced condyle. This tenderness is absent if the extended forearm is pressed against the upper arm in adduction or the normal position. Diagnosis. — Accurate determination of the relative position of the external and internal condyles and olecranon may not aid the diagnosis if, as is common, no displacement of the fragment exists. It is impor- tant to remember that the position of the external epicondyle usually indicates the position of the condyle, as isolated avulsion of the epicon- dyle is extremely rare and occurs almost entirely in connection with posterior dislocation of the forearm. Cases are occasionally seen with a typical displacement of the fractured condyle, usually backward, as indicated by Mouchet; rarely forward. It is natural that under these circumstances the increased distance between the external epicondyle and the olecranon should denote displacement and fracture; the relations, however, may be much more complicated, as the ulna may be dislocated at the same time and the olecranon lie in the cleft between the fragment and the trochlea. The distance of the olecranon from the inner condyle would then be increased. If such a luxation or subluxation complicates the avulsion of the condyle, it is evidenced not only by the marked loss of function, but also by the changed relation of all fixed points. Uncomplicated fracture of the external condyle with backward dis- placement of the fragment is shown by tenderness on pressure, crepitus, and false motion in the sense of a cubitus varus. In certain cases it is possible, in the absence of any great swelling, to feel the sharp edge of the dislocated fragment posteriorly close to the olecranon. In this posi- tion it may be mistaken for the head of the radius on superficial exami- nation, and so the condition is mistaken for backward dislocation of the radius. (Mouchet.) Prognosis. — Involvement of the joint makes the prognosis of fracture of the external condyle unfavorable, as the fracture lies partly within the joint, and callus production and adhesions may cause permanent impairment of motion. For this reason it is important to begin passive motion as soon as possible — that is, at the end of the second week, other- FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 183 wise the limitation of motion is overcome with increasing difficulty. The case shown in the .r-rav picture (Fig'. 118) recovered with full motion. Treatment. — For the average case with slight displacement the plaster splints, plaster strips or other strip splints applied for between two and three weeks with the joint semiflexed will give good results. To prevent displacement of the fragment, the hand can be pronated strongly. The most rational treatment, however, is extension with the arm outstretched to prevent the possibility of cubitus varus. The extension apparatus is easily attached to any bed; a board is laid in sideways, a pulley attached at its outer end, and the weight and traction cords adjusted over it. The arm may be placed upon an inclined pillow; no traveller is necessary. Reduction is often difficult. Operation may be necessary both to determine the conditions present and to replace and suture the fragment in its normal position. Kocher, among others, has resorted to this pro- cedure in many cases, and has found the fragment rotated in one case through ISO degrees, the fracture-surface facing outward. Beck has made the same observation. Mouchet found the fragment had rotated through 00 degrees in 4 different cases. Incision and exposure of the joint are not difficult, as the posterior surface of the external condyle is readily accessible, and the radial nerve is easily retracted and protected. If, upon incising and exposing the joint, suture of the fragment presents any great difficulty, Kocher advises its removal. His experience shows that such a resection does not essen- tially disturb the function of the joint, and may be therefore employed without hesitation. Further, the removal of the condyle materially im- proves the chances for recovery, as the formation of callus is not so liable to encroach upon the joint. Kocher cites the good functional results of this operation, and recommends resection of the external condyle secondarily for the cases of fracture of the external condyle followed by severe loss of function. The question of operative interference usually arises after recovery in the cases in which expectant treatment — namely, failure to reduce displacement of the fragment — has produced marked functional disturb- ance. At the present time there is no doubt that the relatively slight danger of such operations upon the joints and the possibility of obtaining accurate information with the .r-rav of the conditions present will lead to greater developments in this field. Exuberant callus production about the dislocated fragment may in- crease to the dimensions of an exostosis on the posterior surface of the joint, as noted by Mouchet, and greatly limit motion. Fracture of the External Epicondyle. — Fracture of the external epi- condyle is relatively infrequent and needs only brief mention. It occurs almost exclusively from direct violence acting upon the outer side of the lower end of the humerus and chipping off small pieces of the epicondyle. The fracture is frequently complicated by lesions of the skin. Under these circumstances the diagnosis is not difficult. In simple fracture, in favorable cases, the mobility of the epicondyle and localized swelling and tenderness are recognizable. Exceptionally slight passive ulnar adduction 184 INJURIES OF THE ELBOW-JOINT. of the forearm is possible. Slight tears and avulsion of the external epi- condyle as well as of the internal epicondyle often accompany backward dislocation of the forearm. In children fractures of the epicondyles are essentially epiphyseal separation, as the epiphyseal line of the external epicondyle begins to ossify at about the fifteenth year. The so-called "tear-fracture" accom- panying luxation is almost without exception a separation in the epi- physeal line. Treatment. — In the simple form, in which the fracture-line is extra- articular, rest for about eight to fourteen days is sufficient to overcome the pain, sensitiveness, and swelling. There is usually no loss of function. Fig. 119 represents a tear-fracture of both epicondyles in a thirteen- year-old boy. The fracture on both sides is recognizable as a separation in the epiphyseal line. In the external condyle several small primary Fig. 119. Fig. 120. Fracture of the external and internal epicon- dyles. Boy aged 13 years. Fracture of the external epicondyle. iGurlt. i centres are visible. The primary centres appear in the external con- dyle at about the ninth year. In the fourteenth or fifteenth year the epiphyseal line is calcified. In this case the tear-fractures resulted from hyperextension of the elbow-joint in falling upon the hand, producing posterior dislocation of the forearm. The fragments, sensitive to pressure, could be moved about beneath the skin. Union followed without loss of function. Fracture of the Internal Epicondyle. — Fracture of the internal epi- condyle is of frequent observation, especially in youth. As the epiphyseal line exists until the fifteenth or sixteenth year, the injury frequently occurs as a separation of the epiphysis up to this age. From its exposed position the internal epicondyle is subjected to direct violence, as a fall upon the abducted arm, or a blow; more fre- FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 185 quently, however, the break occurs as a tear-fracture. The internal epicondyle is the point of insertion of the strong internal lateral ligament. Sudden movements, subjecting the ligament to abnormal tension, usually tear the epicondyle, but not the ligament. Such tears, affecting the in- ternal ligament, result from abduction of the forearm as well as from hyperextension. By a fall upon the outstretched arm hyperextension is often the cause of posterior dislocation of the forearm, and, as is easily understood, the cause of avulsion of the inner epicondyle. Fracture of the inner epicondyle may he at times mistaken for a posterior dislocation. For many reasons tear-fracture of the inner epicondyle may be regarded as an injury predisposing to luxation. In all of the author's cases of posterior dislocation of the forearm during the tenth to the fifteenth years, the period of greatest frequency, the internal epicondyle was torn off. It is justifiable, therefore, to claim an etiological relation between luxation and separation of the epicondyle in the epiphyseal line in this period. The fracture is associated almost constantly with lateral dis- location, especially outward, of the forearm. Knowledge of the production of the fracture by hyperextension is important to understand the not infrequent intra-articular hemorrhage accompanying tear-fractures of this epicondyle. The explanation is that simultaneous with the fracture the anterior part of the capsule is torn by the hyperextension, thus giving the symptoms of an extra- articular fracture combined with an apparent intra-articular lesion. The intra-articular hemorrhage may result exceptionally from a joint-fracture, as fracture of the epicondyle is frequently combined withT- and Y-shaped fractures and the so-called diacondyloid fractures. Such joint-fractures are excluded or confirmed by testing the mobility. In simple avulsion of the epicondyle joint-motion is complete. Crepitus of the fragment is usually obtainable. By the traction of the ligament the fragment is usually displaced down- ward. The fragment may be concealed by circumscribed extravasation or be palpable at times in the region of the ulnar nerve which it covers. The fracture is evidenced, in addition to the local extravasation, by slight abnormal mobility — radial abduction — of the forearm. Fracture of the epicondyle by direct violence may be accompanied by injury of the ulnar nerve, shown by numbness or paralysis in the area supplied. These paralyses usually recover quickly. Xo splint is able to hold the fragment in its normal place if it is dislocated downward. During recovery attention should be directed to preventing joint-stiffness. At the end of eight to ten days active and passive motion is advisable. Treatment by extension with the arm outstretched, which, according to Bardenheuer, is supposed to effect fixation of the fragment in its normal position, appears illusory, as with the forearm extended the internal lateral ligament is not relaxed. In all cases with marked displacement the question of operation must be considered. The fragment may be sutured in place with catgut, as it is usually in part cartilaginous. If fixation is difficult, the fragment may be excised and the ligament sutured in place. 186 INJURIES OF THE ELBOW-JOIST. Excision is indicated further, as noted by Koeher, for cases in which joint-motion is interfered with by malunion — for example, if the frag- ment lies so near the joint as to prevent flexion and extension. The incision is made to the inner side of the olecranon and the ulnar nerve retracted. It may not be necessary to open the joint. Fracture of the Inner Condyle. — The reason of the relative infre- quency of this injury as compared with fracture of the external condyle has not been satisfactorily explained. The cause is usually a direct blow or fall upon the inner surface of the elbow. The diagnosis is made usually only by careful examination of the swelling, tenderness, and abnormal passive mobility of the forearm in the sense of abduction and hyperextension. If the fragment is displaced, abnormal mobility may be obtained by direct palpation. Fig. 122 is from a woman sixty-four Fig. 121. Fig. 122. Upper and lower limits of fracture of the internal condyle. (Stimson. Fracture of the internal condyle. Woman ajjred 61. vears old, who fell while carrying a package under the arm and struck upon the posterior surface of the forearm. The blow upon the ulna and the olecranon drove the latter against the condyle. After fourteen days of fixation in a plaster-strip splint motion was begun, which on account of the age of the patient was possible only to GO degrees. Complete reposition of the displaced fragment was impossible. (Fig. 123.) Gurlt reports several cases of fracture of the inner condyle in which the ulna, remaining in contact with the fragment, was dislocated backward. The radius may thus be dislocated partially or completely and project back- ward so that the joint-surface of the head is palpable. Id those frac- tures combined with dislocation, the easy reducibility of an apparently superficial luxation points to a complication and demands an accurate determination of the fixed bony points. FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 187 Prognosis. — Little is known of the prognosis of the fracture on accounl of its rarity. Treatment. — Kocher recommends ;i plaster splint for two or three weeks or continuous extension. Reduction is best accomplished by traction upon the upper end of the Hexed forearm in the axis of the upper arm. Motion should be begun in two weeks ;it the latest in order to prevent or overcome adhesions in the joints. Diacondyloid Fracture; Separation in the Epiphyseal Line. By this term is meant fracture or avulsion of the articular process alone. The fracture-line lies below the epicondyles; usually the surgeon is dealing with a separation of the epiphysis. (Fig. 124.) It occurs most commonly in childhood up to the fifteenth year. Fig. 123 Fig. 124. Fracture of the internal eondvle. Line of the lower epiphysis. According to Kocher \s experiments, the fracture is produced by a direct blow against the elbow in the axis of the humerus. The condyloid process is tints broken off. The normal curve of the cubital process favors this form of injury. In childhood the process may be torn off during hyperextension by the pressure of the tense anterior part of the capsule. The fracture, if purely intra-articular, is difficult to diagnosticate. The swelling of the joint, the tenderness, and the marked loss of active motion indicate a severe intra-articular lesion. False motion is possible; with the epicondyles fixed, the forearm may be pushed outward, inward, and even backward and forward. The backward displacement may be such as to resemble posterior dislocation of the elbow. Occasionally the edge of the fragment may be felt at either side of the olecranon 188 INJURIES OF THE ELBOW-JOINT. behind. The extension method with the arm outstretched gives the best fixation, the tension of the capsule holding the fragment in its normal position. In children fixation with the arm extended should not be continued longer than ten to fourteen days. Afterward the tendency to stiffness should be overcome by gradual flexion. Fig. 125 shows a separation of the epiphysis in a child of four years. The primary centre in the capitulum is displaced inward with the bones of the forearm against the lower end of the humerus. The causation in this case was not stated. Fig. 125. Fig. 126. Diacondyloid fracture of the humerus with inward displacement. Separation in the epiphyseal line. Child aged four years. Fracture of the capitulum humeri with forward dislocation. Fracture of the Capitulum of the Humerus (Eminentia Capitata). — This form of fracture, not uncommon according to Kocher, is scarcely mentioned in the text-books. The lesion consists in a peeling off of the capitulum. It is observed usually in the second decade, and is caused by the same forces which produce fracture of the external condyle — that is, a fall upon the hand; also pressure of the tense capsule against the eminentia is supposed to push off the cartilaginous covering like a cap. Symptoms. — The symptoms of the fracture are fairly characteristic, although the loss of function and pain are not so marked as to point immediately to a fracture. On superficial examination the break may be overlooked. The arm is held fixed in incomplete extension. Passive motion may be possible to almost complete extension. Sometimes the resistance felt during extension gives way suddenly and motion becomes entirely free. This happens probably from the slipping back of the fragment into place. Supination is usually impaired and painful. FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 189 Careful inspection of the joint after the swelling has subsided reveals a prominence near the head of the radius. On palpation it may have the peculiarities of a floating cartilage. In extension the sharp edge of the fragment is easily palpable below the external epicondyle; the frag- ment may possibly he pushed into the joint-cavity or with certain move- ments slip in spontaneously. Diagnosis. — Alternating freedom and loss of motion should make the surgeon think of this form of fracture. If a fragment is demonstrable, it can be confused only with a fracture of the head of the radius; the latter is excluded by palpation of the head of the radius in pronation and supination. In one case seen flexion and extension were greatly limited and painful, also pronation and supination. Symptoms attrib- utable to wedging of the fragment were not present. Treatment. — The diagnosis being established, immediate removal of the fragment by operation is advisable, and is accomplished without difficulty through an incision on the outer side of the joint after incising the capsule. The results of such interference are very favorable. Pro- longed fixation with splints is unnecessary. For a critical analysis of a'-ray pictures of fractures at the lower end of the humerus during the age of development, a knowledge of the normal epiphyseal growth is necessary. In the second year a primary centre appears in the capitulum (Figs. 118 and 125); in the tenth or eleventh year in the trochlea. (Fig. 136.) The primary centre in the trochlea, from its serrated outline, may be easily mistaken for a splinter. The epiphyseal line ossifies in the seventeenth or eighteenth year. In case of doubt it is best to compare radiographs of both elbows. Fractures of the Upper Ends of the Bones of the Forearm. The fact that the head of the radius and the incisura semilunaris of the ulna are enclosed within the capsule of the elbow-joint stamps all fractures of the bones of the forearm occurring within this region as intra-articular. For this reason it seems best to describe them following fractures of the lower end of the humerus. Of the fractures of the upper end of the radius, those to be considered are fracture of the head and the rare fracture of the neck; of fractures of the ulna, the relatively frequent fracture of the olecranon and avulsion fracture of the coronoid process. Fracture of the Coronoid Process of the Ulna. — This fracture is rare, and is usually associated with backward or lateral dislocation of both bones of the forearm. A dislocation that is easily reducible points to the existence of this fracture. According to Lotzbeck, the fracture results from a fall upon the ulnar border of the hand with the arm somewhat flexed. The blow is trans- mitted to the ulna and thence to the coronoid process, which is broken off by the counterpressure of the trochlea. A few cases are reported of supposedly pure tear-fractures resulting from contraction of the brachialis. 190 INJURIES OF THE ELBOW-JOINT. The fracture-line lies near the tip of the process, and at the base it is extremely rare; the author has seen it in 1 case accompanying outward dislocation of the forearm. As the coronoid process is partly covered by the strong fibrous attachments of the lateral ligaments, and further by the annular ligament, which is in turn strengthened by the tendon of the brachialis, any marked displacement of the fragment is impossible. Symptoms. — On account of the deep and covered position of the process the fracture may be almost without symptoms. Urlichs describes them briefly as follows: If a patient who has fallen upon the hand complains of pain localized in the plica cubiti; if swelling exists and the articular surfaces and fixed points are in their normal position and indicate no change; if movement, active and passive, is impaired; and finally, if a somewhat doubtful friction-sound can be elicited at the site of the coronoid process, the surgeon is justified in diagnosticating a fracture limited to the process. Occasionally pain produced by forced flexion is characteristic, the process being pressed against the anterior fossa. Prognosis. — The usually slight displacement of the small fragment is followed as a rule by bony or fibrous union; the prognosis is therefore favorable. Treatment. — The treatment is simply rest and fixation for eight to ten days with the arm semiflexed. Fracture of the Olecranon. — Fractures of the olecranon are relatively frequent, and result from direct violence on account of the exposed position of the bone. A blow or fall upon the olecranon with the arm semiflexed may produce a direct fracture. If the periosteum and the tendinous fibres of the triceps insertion remain intact, the fragments remain in contact so that the fracture-line may not be palpable and the fissure recognizable only with the finger-nail. As a rule, however, the upper small or large fragment is drawn upward by the triceps and the separation of the fragments easily recognizable. Direct violence often produces splintering of the upper fragment. Less frequently the fracture may occur from sudden contraction of the triceps, as in the act of throwing; also from hvperextension, as by a fall upon the hand. The olecranon is jammed against the posterior supratrochlear fossa and the tip chipped off. According to Oberst, in fractures resulting from muscular traction, only a shell of the corticalis is broken off, the fractures therefore being extra-articular in contrast to those produced by direct violence. The middle of the process is the common seat of fracture; fractures of the base have been observed not infrequently by Oberst and by the author. Fracture of the olecranon may be combined with forward dislocation of the forearm. Symptoms. — With complete separation the symptoms of fracture of the olecranon are unmistakable. The patient allows the arm to hang at the side and supports it with the other hand. Flexion is possible but painful ; extension is impossible. The action of gravity upon the forearm may simulate the act of extension if the arm is allowed to drop from PLATE IV FIG. 1. Old Oblique Fracture of Humerus, with Reversal and Overriding. Good Union. (Sollev.) Fracture of Olecranon, Man Aged Forty-eight Years. (Solley.) FRACTURES OF ENDS OF HONES FOUMINO KL BOW- JOINT. \\)\ its iionii.il position with the hand supinated. To avoid error, extension should be attempted againsl resistance, or, better still, by having the patient extend the arm against the lone of gravity, namely, by having the patient bend over until the posterior surface of the upper arm faces I ']<;. 127. Fracture of the olecranon, fibrous union. (Malgaigne.) upward. If the olecranon is fractured, the forearm cannot he lifted to a horizontal position. On palpation the cleft of the fracture line is easily felt. The presence of ecchymosis, swelling, and intra-articular hemor- rhage is significant. Crepitus may be sometimes obtained by rubbing Fig. 128. Fig. 129. Development of the primary centre in the epiph- ysis of the olecranon (thirteenth year). Normal epiphyseal line of the olecranon partially ossified (eighteenth year). the upper fragment against the lower. If separation is prevented by the integrity of the periosteum and tendons, extension of the arm may be possible, but with less force than in the other arm and accompanied with pain; even in this case accurate palpation will demonstrate a fracture. 192 INJURIES OF THE ELBOW-JOINT. As shown by x-ray pictures, there is a marked similarity in the size and displacement of the fragments in the average case. Fig. 130 shows the usual form of this fracture with separation. In regard to x-ray pictures of fractures of the olecranon, the conditions of ossification of the epiphysis must be understood to avoid the deception otherwise inevitable in young subjects. One, occasionally two, primary centres appear in the epiphysis of the olecranon in the tenth to the twelfth year. Complete ossification of the epiphyseal line occurs between the seventeenth and nineteenth years. Fig. 128 shows the outline of the primary centre in the thirteenth year; Fig. 120 the appearance during ossification of the epiphyseal line. The latter is easily mistaken for fracture, and the former has been regarded as a fracture in several instances and described and reproduced as such recently. Cases of pure epiphyseal separation of the olecranon occur, as demonstrated by a case of v. Brans. Prognosis. — The prognosis in cases without displacement is favorable; in those with marked separation of the fragments bony union is impos- Fig. 130. Old fracture of the olecranon with separation, fibrous union, and good junction. sible without further treatment. Bony union, however, is not absolutely essential to good function. Fig. 130 is an x-ray picture of a fracture recovering without impairment of power or motion. The remaining portion of the olecranon grew in the course of time, so that the olecranon finally regained its normal size. Interposition of parts of the capsule or tendons may prevent bony union. Treatment. — The important task is to obtain union of the fracture- surfaces, and many plans are proposed for this purpose. Lauenstein recommends puncture of the joint to remove the intra-articular hemor- rhage which tends to increase the separation. This is advisable only in cases of very profuse intra-articular hemorrhage, as the extravasation is usually absorbed, if aided by rest and light compression, in the course of eight days. For apposition of the fragments fixation with the arm FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 193 extended in either a plaster or plaster-strip splint suffices for the average case. In using such a splint, to hold the upper fragment in position after drawing it down forcibly, a figure-of-8 adhesive plaster bandage may- he applied firmly into the notch above the olecranon, crossing in front of t he ell x >\v. The same effect may be obtained by means of a long strip of plaster reaching from above the olecranon to the forearm [combined with a circular strip fitting into the groove above the olecranon]. The arm should not remain in the splint longer than ten days. At the end of that time the author always flexes the arm gradually to avoid stiffness; in the fourth week massage and passive motion, naturally avoiding forced flexion at the outset. Sachs has recently abandoned all fixation, advising massage from the beginning, and reporting a number of good results from such treatment. Fig. 131. A' Laminated fracture of the olecranon : a, upper fragment; b, external condyle. (Stimson.) The author doubts whether this method will meet with general accept- ance. The results obtained by Sachs can be explained equally well by the fact that fractures of the olecranon recover with good function in spite of marked diastasis. The most rational treatment, although usually unnecessary, is suture of the bones. This may be done at once, or, as in the case of the patella, in a few days after absorption of the extravasation. Through the incision — preferably a flap-section to prevent contact of the skin and bone sutures — the interposed parts of the capsule are excised and the bone- surfaces smoothed off if necessary. The fragments are drilled and sutured with thin wire [preferably chromicized catgut]. Konig recom- mends fixation of the joint in semiflexion for fourteen days after sutur- ing, fixation in extension being inadvisable on account of the difficulty and painfulness of the first attempts at flexion. Suture of the bones may be done secondarily to overcome the unsatis- factory results of other treatment. It is also applicable to those compound fractures in which the condition of the wound gives a fair promise of an aseptic course. As the fracture usually results from direct violence, it Vol. III.— 13 194 INJURIES OF THE ELBOW-JOIST. is compounded with great frequency. Compound fractures in which the danger of infection is great, should be fixed in semiflexion in antici- pation of ankylosis. Fracture of the Head of the Radius. — This is a pure intraarticular fracture. A frequently observed form is the so-called chisel-fracture, a segment being broken off obliquely from the head, as in the accom- panying illustration. (Fig. 132.) The fragment may be completely separated or merely fissured. If the fragment is free, it may act as a corpus mobile in the joint. As a rule it is held by periosteum. Etiology. — The cause is indirect violence, espe- cially a fall upon the hand with the forearm mod- erately flexed and pronated. The anterior part of the head which lies in contact with the humerus is thus driven against the articular surface of the latter and the margin of the disk-shaped articular surface is knocked off. v. Bruns first called attention to the relative frequency and typical form of the fracture in 1880. If in falling upon the hand the arm is more abducted, the outer side of the head receives the chief pressure and a segment of the outer cir- cumference will be broken off. Symptoms. — The symptoms may be concealed by intra-artieular hemorrhage. On palpation pain in the region of the head denotes an injury of the and extension, pronation and supination may be on the other hand, during rotation a broadening of the head may be recognizable, but, as emphasized by Malgaigne, may be mistaken for dislocation of the head. Crepitus, which may be noticed even by the patient, and the slight movement of the fragment during pronation and supination are diagnostic. Frequently the fragment and its mobility may be felt, as well as the line of cleavage. As already seen, a fall upon the hand is an etiological factor in many other forms of injury. It is therefore natural that the f tin- head <>t the radius, v. Bruns. latter. Flexion slightly impairei II! A' TUBES OF ENDS OF BOXES FOBMING ELBOW JOINT. 195 Fixation for two weeks in any of the ordinary splints suffices for this fracture. It is better, however, to remove the splint frequently and carry oul moderate movements. In immobilizing, the arm should be semiflexed, the hand semipronated, and the latter position maintained by carrying the strips to the fingers. In addition to the usual chisel-fracture, fissures and incomplete frac- tures have been seen, usually accompanying dislocations; also in con- nection with fractures of the external condyle and capitulum humeri, and fractures of the ulna and shaft of the radius. Epiphyseal separation of the radial head is little known — in fact, very rare. The diagnosis can he made only with probability from the local appearances, which are similar to those of the following fractures. A primary centre appears in the head of the radius in the fifth or sixth year; the epiphyseal line ossifies in the seventeenth or eighteenth vear. Fracture of the Neck of the Radius, — This fracture is rare, and results from direct violence, also indirect, presumably from forced pronation. In regard to the etiology and mechanism, accurate observa- tion and investigation are lacking. The fracture is supposed to occur in combination with backward dislocation of the ulna and with fracture of the coronoid process. In a case observed by Oberst it accompanied posterior dislocation of the forearm, and resulted from a blow upon the elbow received in a fall from a bicycle. Symptoms and Diagnosis. — The symptoms are obtained only by care- ful examination of the head of the radius demonstrating its separation from the shaft by its failure to accompany the movements of the latter in pronation and supination. The diagnosis is aided by local tenderness, swelling, and crepitus. Rotation is painful and limited. The fracture- ends may be displaced. Treatment. — Fixation should be in semiflexion to prevent displacement of the shaft by the contraction of the biceps. Subluxation of the Radius. — Under the name "derangement interne" is presented a symptom-complex frequently observed in children and resulting from violent traction upon the forearm. After such an injury the child allows the forearm to hang relaxed as if paralyzed. Usuall) no injury is demonstrable at the joint. As to the nature of the joint-disturbance, opinion is divided whether it may be a constriction of the capsule or subluxation of the radius. Streubel's experiments speak for the latter view. He demonstrated on the young cadaver that by forced pronation and extension of the forearm the ligaments and capsule could be stretched in such a manner as to pro- duce a gap between the radius and eminentia capitata into which the capsule could enter. If the forearm was not pronated this condition persisted. On extending and supinating the arm, however, the normal relations are restored. The same condition could be produced by supi- nation. Hultkrantz, in studying the anatomy and mechanism of the elbow-joint, notes that in young children the demarcation between the capitulum radii and shaft is less pronounced, and the entire capsule — 196 INJURIES OF THE ELBOW-JOINT. that is, the annular ligament — is weaker and more yielding, so that on the cadaver a partial dislocation of the radius could easily be produced by rotary movements. The question deserves further investigation, particularly with the aid of the .r-ray. In the presence of the above-mentioned peculiar symptom-complex in children attempts at supination of the forearm are painful. The dis- turbance is overcome by supination of and traction upon the arm fol- lowed bv flexion, after which the child is able to use the arm again immediately. Complicated Fractures of the Elbow-joint. — Marked violence, ma- chinery injuries, street accidents, etc., often cause simultaneous fracture of the lower end of the humerus and of the bones of the forearm. Such fractures are usually complicated by lesions of the skin and soft parts. The same principles apply to their treatment as in compound fractures, especially those of the joints. Based upon the results of modern asepsis and antisepsis one can recommend for such cases a fairly comprehensive conservative surgery. The soft parts are to be cleaned, all loose splinters of bone removed, and the site of fracture covered immediately if possible with a skin- flap. According to the subsequent course will arise the question of amputation of the humerus or resection of the elbow-joint. In the event of injury of the large vessels or extensive destruction of the skin accom- panying severe compound or splinter-fractures, amputation of the humerus may be necessary, especially in old individuals, in whom infec- tion of the bone and of the joint is always more dangerous than in young and healthy subjects. Gunshot-fractures of the elbow-joint require brief mention. Aside from the vast statistics of such injuries in war, cases of this sort are rare. It is not the purpose of a text-book of practical surgery to discuss the earlier methods of treatment of complicated gunshot-fractures of the elbow-joint and their results, as the treatment was carried out partly tinder unfavorable circumstances. The bone lesions produced at close range by the modern small-calibre bullets and their explosive action are much more extensive than those observed in earlier wars, as has been verified by accurate experiments. In such cases with extensive laceration of the soft parts it is certain that conservative treatment will be less applicable than in previous wars, and amputation of the humerus will be with greater frequency the only possible treatment. On the other hand, the small-calibre bullet at long range, according to the experience of recent wars, produces a much more favorable injury in the bone as well as in the soft parts than the large-calibre bullets without metal covering previously did. Among interesting gunshot injuries should be mentioned the severe lesions related by v. Bruns as produced by the English Dum-dum bullets — small-calibre, lead-tipped bullets — and by the new hollow-point bullet. The accompanying photograph and x-ray picture (Figs. 133 and FRACTURES OF ENDS OF BONES FORMING ELBOW-JOINT. 197 134) show the enormous damage to the soft parts and the complete destruction of the ends of the bones produced by these bullets. The results of the treatment of gunshot injuries of the elbow-joint in late wars interest surgeons in only one respect, namely, in regard to the results of conservative treatment and of resection of the elbow. Fig. 133. Gunshot wound of the elbow-joint marie by a lead-pointed Duni-dum bullet at close range. (v. Bruns' experiments, i According to the statistics of Dominik, among 163 cases of gunshot injuries of the elbow-joint, in 133 (81.6 per cent.) ankylosis occurred; while in only 10 cases (6 per cent.) was free motion preserved. Resection , on the other hand, gave good results, presumably in 52.8 per cent. These results should certainly be significant for the question of treatment of complicated gunshot-fractures, even in war. All operative measures are limited in war, however, on account of the unfavorable conditions, 198 INJURIES OF THE ELBOW-JOINT. to the very urgent cases, so, in spite of the above statistics, conservative treatment will still be the rule in the future for all slight and moderate gunshot injuries, even where ankylosis is threatened. Fig 134. X-ray of Fig. 133. DISLOCATIONS OF THE ELBOW. An accurate knowledge of the normal anatomy of the elbow-joint is as essential for the diagnosis and treatment of dislocations as for the diagnosis and treatment of fractures. The determination of the fixed bony points, the relation of the capsule and the ligaments are mentioned in the introduction to the treatment of fractures. The mechanism of the joint is described at the same place. As the elbow-joint consists of the articulation of three different bones, the forms of dislocation are naturally manifold. Both bones of the fore- arm and each bone individually may be dislocated in various directions. DISLOCATTO.XS OF THE ELBOW. 199 Dislocations of the elbow-joinl arc relatively frequent. They occur more commonly in children and young subjects. Women and children are affected more frequently than men. Petersen gives as the cause in women and children a normally existent possibility of hyperextension, which would mean a certain predisposition to this injury. Surgeons distinguish : Dislocation of both bones of the forearm: 1. Backward. 2. Lateral. '.]. Forward. 4. Divergent. Dislocation of one bone of the forearm: 1. Dislocations of the ulna. 2. Dislocations of the radius: (a) backward, (b) outward, (c) forward. Dislocation of Both Bones of the Forearm. Backward Dislocation. — This frequent form, one might almost say the normal form, of dislocation of the elbow-joint is usually pro- duced by a fall upon the hand with the arm outstretched — that is, by Fig 135. Backward dislocation of both bones of the forearm. hyperextension. In this manner the forearm is hyperextended, the tip of the olecranon is jammed against the fossa supratrochlearis posterior and forms a fulcrum over which the lower end of the humerus is lifted for- ward. The anterior portion of the capsule is torn from the resulting tension and the lower end of the humerus slips through the rent. The radius and ulna slip backward and the coronoid process may lie upon the trochlea or behind it. The backward dislocation is thus completed. 200 INJURIES OF THE ELBOW-JOINT. The .x-ray picture (Fig. 135) shows the relation of the ends of the bones to each other. While the author is obliged to regard the above mechanism of back- ward dislocation of the forearm as the usual one, the dislocation may occur in other ways, the possibility of which is shown to him more by experiment than by experience. Schiiller was able to produce the dis- location by a heavy blow upon the posterior surface of the upper arm, the elbow-joint being flexed. In this manner the joint-surface of the humerus is driven forward. The explanation of Schiiller, also founded upon experiments, is reason- able, namely, that by forced lateral movements, especially radial abduc- tion, dislocation results from the laceration of the inner lateral ligament, the bones of the forearm, especially the coronoid process, being pushed backward beneath the trochlea. Taking into consideration the normally existent radial abduction, cubitus valgus, which is especially pronounced in females, such an abnormal forced abduction by falling upon the hand with the arm flexed or extended seems possible. The degree and form of injury of the joint, capsule, and lateral liga- ments vary according to the mechanism of origin. The involvement of the soft parts in posterior dislocation of the fore- arm may be slight, the swelling insignificant, and the prominent bony points recognizable on inspection; in other cases the lesions of the soft parts may be severe. The brachialis anticus may be torn by the lower end of the humerus, and exceptionally the median nerve and the cubital artery may be damaged. The cubital process has been known to per- forate the skin in front of the joint. Diagnosis. — The diagnosis of the usual form of posterior dislocation of the forearm is not difficult. It is even less excusable not to make the diagnosis at once, as the failure to do so is more serious than in the case of fracture, for severe functional disturbance always persists if reposition is not timely and complete. On inspection the arm is moderately flexed, between 140 and 150 degrees; the patient either allows the arm to hang or supports it with the other hand. If the patient is sitting, the arm is usually supported upon the thigh. In the absence of any marked swelling the tightened triceps tendon projects like a cord upon the posterior surface, the contour of the latter being curved backward. To the outer side of the triceps tendon is a deep depression in which the sharp outline of the head of the radius is recognizable beneath the stretched skin. On palpation below and to the outer side of the olecranon is felt the disk-shaped articular surface of the head of the radius, further identified by rotating. Above the olecranon deep pressure must be made in the depression to touch the posterior surface of the humerus. The olecranon lies at a greater distance from the epicondyles than in the other arm and above the line drawn between them. The head of the radius lies farther behind and below the external epicondyle than normally. On the anterior sur- face of the joint the cubital process is felt as a prominence pushing the soft parts forward. The axis of the upper arm meets that of the lower DISLOCATIONS OF THE ELBOW. 201 arm anterior to the point of intersection on the normal side. Palpation may be greatly hindered by much swelling. Most important is the test of motion; as the displacement of the dislocated part, in this ease the forearm, results from violence, and the arm is fixed by the still intact ligaments, marked limitation of motion is the rule. There is an elastic resistance to motion, unyielding to even considerable force. This fixation and loss of active and passive motion are differential against fracture, particularly against the in other respects not dissimilar supracondyloid fracture, in which, as related, a similar deformity is produced by the backward displacement of the lower fragment. In fracture, however, the fixed points are not altered. Prognosis. — If the diagnosis and treatment are immediate, the prog- nosis for reduction and functional restoration is usually favorable. If the injury is recent and uncomplicated, reduction is generally simple and easy. At the end of three or four weeks, on the other hand, reduc- tion is often extremely difficult and sometimes impossible in spite of all manipulation. This does not imply that all dislocations are irreducible at the end of this time. Cases are known in which reduction was accom- plished in the usual manner at the end of several months, but they are exceptional. As a rule dislocations remaining unreduced for several weeks require operative interference, a fact which shows the importance of immediate diagnosis and reposition. Treatment. — Reduction is best accomplished by simple traction on the forearm, the upper arm being held by an assistant. The author has found this method satisfactory in almost every case. The forearm may be rotated and flexed and extended slightly with advantage during trac- tion. Konig is the only one to relate this form of reposition. It requires much less force than reduction by hyperextension. Anaesthesia is advisa- ble in all methods, although reduction by simple traction is often effected without it. Many other methods are suggested, among them the so-called physiological method of Roser, which attempts reduction in the reverse direction of origin. The forearm is hyperextended, a fulcrum thus being established on the posterior surface of the upper arm. The coronoid process is thus lifted off and freed. By traction on the forearm the joint- surfaces of the bones of the forearm are drawn forward against those of the cubital process, and by flexion the normal position is restored. The author does not recommend Roser's method for the first or for general application. Forcible hyperextension not infrequently causes new in- juries by stretching the capsule and ligaments on the anterior surface. For this reason the physiological method is inferior to every manipula- tion which accomplishes reduction more simply and with less violence. The old method of forced flexion is often valuable. The arm, flexed, is laid upon the forearm of the operator, the latter acting as a lever, and reposition effected by traction upon the forearm with direct pressure upon the upper end. The so-called " distraction " method of Dumreicher consists in exerting downward traction upon the upper part of the fore- arm in the axis of the humerus, at the same time pulling upon the forearm in its axis as it is brought gradually to semiflexion. 202 INJURIES OF THE ELBOW-JOINT. The above methods may be tried, but simple traction on the forearm is sufficient for recent cases and rarely fails. Reduction accomplished, rest is enforced for eight days to allow of resorption of the swelling and hemorrhage; then motion is begun and continued until it is entirely free. The surgeon should guard against secondary shrinkage and the resulting stiffness of the joint which may occur at a late period. This subsequent impairment of motion may depend upon lesions of the capsule, ligaments, or bones peculiar to this form of dislocation. As this applies usually to the anterior part of the capsule and the adjacent ligaments, the elbow- joint shows a tendency to become flexed, and especially limited in ex- tension. It is necessary to combat forcibly this tendency to contractures by passive motion. Mechanical apparatus or manual traction and ex- tension are serviceable. The patient may often obtain complete exten- sion of the arm by carrying a weight. Slight lesions of the bones complicating posterior dislocation may make the diagnosis difficult. Easy reducibility by simple traction may signify that there is a fracture of the coronoid process. In such instances the dislocation is as readily reproduced by a blow. As mentioned, posterior dislocation occurs with striking frequency from the tenth to the four- teenth year. In all luxations at this age the author has found a tear- fracture of the internal epicondyle in the epiphyseal line. To him it appears that this fracture should not be regarded as an adventitious accompaniment of the dislocation, but rather that this fragility of the epi- condyle at the epiphyseal line determines the surprising frequency of dislocation up to the age at which the epiphyseal line ossifies. (See Fig. 119.) Fracture of the external condyle frequently accompanies posterior dislocation, as recent away examination has taught. Crepitus may be distinct, and is then positive evidence. The chipping off of small fragments can often be only surmised unless shown by the a;- ray. If small fragments occasion considerable loss of motion, they should be removed. In individual instances their removal may be difficult. In some cases simple incision is sufficient; in others, extensive exposure of the joint may be necessary. For the details of the operation for this purpose, namely, an arthrotomy, the reader is referred to the various sections on Arthrotomy, Resection, and Reposition of Old Irreducible Dislocations. Irreducible Backward Dislocation.— Backward dislocation of the forearm usually becomes irreducible in from three to four weeks, if for any reason reduction does not immediately follow the accident. In the interval the swelling gradually subsides and motion is somewhat regained. The shrinkage and cicatrization of the capsule, ligaments, and surround- ing soft parts fix the bones, so that they can no longer be restored to their normal position. Only a few cases are known in which after months or a longer period reduction was possible. Accordingly, for an old unreduced dislocation there is no choice but operative interference. Where a fair amount of motion has been recovered, as happens excep- tionally, reduction may not be absolutely necessary. DISLOCATIONS OF THE ELBOW. 203 Various operative procedures are suggested for old dislocations. Tren- delenburg and Volker divide the olecranon transversely and suture it subsequently. Trendelenburg advises a flap section over the olecranon to separate the sutures of the hone and skin. The olecranon is cut off carefully with a broad chisel, the ulnar nerve being protected. A good view of the joint can thus be obtained and the radius and ulna replaced. The arm is then extended and the olecranon drilled and sutured with wire. At the end of fourteen days the arm is gradually Hexed and mobilized. v. Bruns recommends partial resection of the lower end of the humerus; both by reason of the simplicity of the procedure and its results, it is preferable to partial resection of the radius and ulna or of the humerus and the head of the radius, or of the end of the humerus and the ulna, or complete resection of the elbow. He makes two lateral incisions to avoid injuring the soft parts. The separation of the soft parts is made difficult by adhesions and cicatrization. The periosteum is peeled back and the bones resected with a Gigli saw or with the ordinary saw after protruding the bone-ends out of the wound. The piece resected should not be too small, not less than lh to 2 inches thick. The joint may be mobilized at the end of the third week. A certain amount of stiffness of the joint is desirable, and is overcome later by mechanical exercises. After-treatment is necessary for several weeks. Resection is not advis- able for patients under fifteen years, as the removal of the epiphyseal line results in disturbances of growth and undesirable shortening of the arm. The method of v. Eiselsberg has given very good results, and is founded upon the fact that the irreducibility of old dislocations is de- pendent upon shrinkage and cicatrization of the soft parts. He opens the joint by two lateral longitudinal incisions. All growths, cicatricial bands, interposed soft parts, and fragments of bone are divided or excised. In this manner the ends of the bones are cleaned and exposed to within h mcri °f the attachment of the capsule. Reposition is then possible in every case. Reduction accomplished, all bands preventing free motion are divided till the elbow-joint is free in all its movements. Several times it was necessary to resect the head of the radius where a fracture of the capitulum prevented proper articulation with the humerus. With appropriate after-treatment, namely, motion at the end of three to five days, and passive motion continued energetically for weeks, v. Eisels- berg's results were very satisfactory, the average mobility being flexion to 60 degrees, extension to 160 degrees. Certain lv these results should encourage more general employment of this method, as it is essentially an ideal procedure by which the normal joint is preserved and good function obtained. Complications may occur with backward dislocation of the forearm in the nature of extensive injuries of the soft parts and of the bones. The median, ulnar, and radial nerves may be torn or completely severed, as demonstrated in a series of cases. The vessels may be injured and give rise to large hsematomata. The muscles may be torn extensively; the end of the humerus may perforate the skin in front. These injuries 204 INJURIES OF THE ELBOW- JOIST. demand appropriate aseptic treatment, excision of the edges of the wound, and cleansing of the cavity. If the articular surfaces are badly soiled or fractured, partial resection may be necessary. Inflammation and suppuration of the joint demand appropriate drainage, which, if insufficient, may necessitate further incision or resection, preferably of the lower end of the humerus. Lateral Dislocation. — The remaining varieties of dislocation require only brief mention, as some are very rare, while others present no difficulty in diagnosis. Lateral dislocations of the forearm are observed most fre- quently in children. Harm, to whom surgeons owe the first comprehen- sive reports, states that among 21 cases 18 were in children, inward dislocation being the more common. C. Hiiter, v. Volkmann, and Spren- gel observed the outward variety more frequently. The dislocation is usually incomplete; the bones of the forearm are displaced either so far outward that the joint-surface of the ulna touches the capitulum, and the head of the radius, lying free, pushes the soft parts outward (Fig. 136) or the bones of the forearm may be displaced inward, the head of the radius touching the trochlea, the ulna lying more or less free at the inner, side of the cubital process. The mechanism of these forms is not explained. Violent lateral pressure combined with rotary movement may be the cause; outward dislocation may result presumably from a fall upon the inner side of the flexed forearm. Triquet demonstrated on the cadaver that inward dislocation could be produced by forcible pronation, the upper arm being fixed. The ligaments and capsule can be severely injured. Frequently the internal lateral ligament is torn or the internal epicondyle torn off, the latter injury being found in all of Hiiter's five specimens from the Langenbeck clinic. Fig. 136 is a characteristic .r-ray picture of incomplete outward dislocation. At the inner side of the ulna lies a round piece of bone recognizable as the avulsed inner epicondyle. The serrated primary centre of the trochlea lies in its normal position above the displaced epicondyle. The defect at the point of attachment of the epicondyle is not shown on account of the slight rotation of the humerus in the picture. Diagnosis. — Diagnosis is often hindered by articular swelling, and not infrequently it is false and the lesion regarded as a sprain. Careful examination, especially under anaesthesia, will demonstrate the bony points; in outward dislocation the head of the radius is very prominent, projecting beyond the external condyle, even the disk being palpable under circumstances; on the inner side part of the trochlea may be felt. In inward incomplete dislocation the external condyle projects abnor- mally; the internal condyle is covered partly or entirely by the olecranon. With much swelling slight deviations of the axis of the forearm are often not easily recognizable. The impairment of motion may vary greatly, being influenced in addition by complicating fractures of the external or internal epicondyle, coronoid process, or head of the radius. The determination of the fixed bony points shows most accurately the relative displacement of the head of the radius, the olecranon, and the epicondyles. DISLOCATIONS OF THE ELBOW. 205 Treatment. — The prognosis is not unfavorable. Reposition is easily effected in recent cases by simple traction on the forearm, accompanied by direct pressure upon the dislocated bones, and, if desired, combined with pronation and supination. Failure to reduce a recent dislocation is due to interposition of the capsule or fragments of hone, and calls for operative interference. The x-ray is indispensable for the diagnosis of hone fragments. The after-treatment consists in rest from eight to ten davs in a splint and sling, followed by passive motion for several weeks. An old unreduced dislocation requires operation to prevent ankylosis, possibly resection of the ends of one or more bones, usually the end of the humerus. Reports on these procedures are few. Fig. 136. Fig. 137. Incomplete outward dislocation of tli forearm. Boy aged thirteen years. Complete outward dislocation of the forearm with fracture of . the internal epicondyle. Man aged twenty years. The so-called complete lateral dislocation is rare. The upper end of the radius and ulna lie at the side of the cubital process of the humerus, so that the joint appears doubled in width. The diagnosis is simple. In complete dislocation outward the forearm is flexed or extended in extreme pronation, and generally abducted — cubitus valgus. (Fig. 137.) The ends of the bones project beneath the stretched skin, as Pitha puts it, like a skeleton wrapped in parchment. In two of the author's cases of outward dislocation the most striking symptom was the prominence of the cubital process, which projected backward and was easily recog- nizable through the stretched skin. The head of the radius lay not to • T I • the outer side, but in front of the olecranon, and could be felt in the crease of the elbow. Reduction was by pressure upon the displaced ends of the bone and traction on the forearm. In one case of complete outward dislocation the arm was extended; the internal epicondyle was torn off in both cases. As a subvariety of this dislocation, particularly 206 INJURIES OF THE ELBOW-JOINT. the outward form, should be mentioned complete rotation-dislocation, in which the forearm is rotated on the upper arm through 180 degrees, the olecranon thus facing forward. Forward Dislocation. — This form results from direct violence upon the olecranon and the forearm from behind, as by falling upon the elbow with the arm flexed. The continuation of the force resulting from the weight of the body drives the olecranon up in front of the humerus and it becomes fixed. The olecranon is not infrequently broken. By experi- ments Streubel demonstrated various other modes of production, such as forced supination or hyperextension to a right angle. Marked flexion, as was formerly supposed, is not a cause. He differentiates an incom- plete forward dislocation, in which the tip of the olecranon rests against the trochlea, and a complete dislocation, in which the posterior surface of the olecranon lies in front of the trochlea. In the incomplete form the forearm is lengthened; the anteroposterior diameter of the joint is diminished rather than increased. On the posterior surface the olecranon is absent; the end of the humerus and the posterior supratrochlear fossa are easily felt. The coronoid process is palpable in the crease of the elbow beneath the tense biceps tendon, and at the outer side a cleft between the head of the radius and the external condyle. The arm is only slightly flexed. In the complete form the anteroposterior diameter of the joint is increased. Behind, the cubital process is very prominent; in front, the upper ends of the bones of the forearm are easily recog- nizable. The few cases known have made a good recovery after reduc- tion. Reposition of the incomplete form is not difficult, the tip of the olecranon being freed from the trochlea by traction upon the forearm in the axis of the humerus, combined with gradually increasing flexion and subsequent forward pressure on the upper arm. In the complete form the forearm is at first strongly flexed, as advised by Monin, and then, with traction upon its upper end in the direction of the axis of the humerus, it is gradually pushed under and behind the cubital process. The severe laceration of the capsule and lateral ligaments which make possible this form of dislocation also facilitate its reduction. The dis- location may be accompanied by fracture of the olecranon. The aim of treatment is then not only reposition, but also to secure union of the fracture by immobilizing in extension. The after-treatment will be found under Fracture of the Olecranon. Diverging Dislocations. — In a few instances backward dislocation of the ulna has been seen associated with forward dislocation of the radius. Pitha regards the injury as a wedging in of the humerus between the bones of the forearm. The annular, interosseous and lateral ligaments, and the capsule are more or less torn. The mode of origin is not deter- mined. Hofia regards the mechanism as that of posterior dislocation, modified by the forward displacement of the radius after laceration of the annular ligament. In experiments on the cadaver the dislocation is possible only after division of the ligaments. The sagittal diameter of the joint is increased, the ends of the bones are easily felt, the arm is slightly shortened and moderately flexed. Reduction is by direct pressure DISLOCATIONS OF THE ELBOW. 207 and traction on the forearm. A few cases have been seen in which the radius was displaced outward, the ulna inward. Dislocations of One of the Bones of the Forearm. Dislocation of the Ulna. Of the isolated dislocations of the ulna, the only important one is the luxation backward, as related by A. Cooper. The ulna is displaced backward upon the trochlea, the radius remains in position. The ulnar side of the arm is thus shortened, the forearm being adducted to the varus position; the arm is extended or flexed slightly. Motion is greatly limited, rotation alone being possible. On palpation the abnormal position of the olecranon is evident. For reduc- tion simple traction may be sufficient; if difficult, it is best to abduct the forearm and then supinate, corresponding to the mechanism of origin in the cadaver. Dislocation of the Radius. — Three forms may be considered: for- ward, backward, and outward. Forward dislocation is the common form. It is produced apparently by a fall upon the hand with the arm extended, or by hyperextension. According to Streubel, it may be pro- duced in the cadaver by radial abduction with the arm supinated, thus tearing the internal lateral ligament. Fracture of the external condyle, of the head of the radius, or of the internal condyle may accompany the dislocation. Direct violence may be the cause, such as a blow or fall upon the posterior surface of the elbow, and particularly upon the head of the radius, slight flexion of the joint favoring the dislocation. A fall upon the pronated hand is supposed to be equally frequent as a cause, the forced pronation being the essential factor. In the cadaver the dis- location is produced without difficulty by forced pronation with the arm moderately flexed. According to Loebker, the dislocation results from abduction or adduction of the elbow-joint with the arm pronated or supinated; forced pronation and adduction producing forward disloca- tion, forced supination and abduction producing backward dislocation of the radius. Symptoms. — In forward dislocation the annular ligament is usually torn. The head of the radius lies beneath the supinator muscles and is easily felt in front of the external epicondvle. Motion is limited, the inability to flex beyond a right angle being characteristic. The forearm is shortened in those not infrequent cases in which fracture of the ulna in the upper or middle third accompanies the dislocation. In such in- stances the symptoms of fracture are added. The picture may be modi- fied further by fracture of the internal condyle, and, according to Loebker, of the external condyle, or by chipping off of the head of the radius. Reduction is not infrequently attended with difficulties. If so, the sur- geon is justified in assuming, although the anatomical proofs are still few, that the disturbing factor is an interposition of the capsule or of the annular ligament. Recent dislocations often reduce easily. Roser hyperextends the arm slightly with simultaneous pressure upon the head. Supination may help. On reduction the arm is put up in plaster at a 208 INJURIES OF THE ELBOW-JOINT. FiCx. 138. right angle, the position of best fixation for the head. Motion may be begun at the end of fourteen days. Operation is indicated if reduction fails. Sprengel confines himself to excision of the interposed parts of the capsule and then sutures the capsule. Resection of the head has often given good results. To avoid the radial nerve, the incision should be lateral, as in this form of dislocation the branch of the nerve always crosses the head and neck from in front. The line of incision should be over the epicondyle, as made by Hitter for total resection of the elbow. Forward dislocation may be accompanied by fracture of the shaft of the ulna, fracture of the external epicondyle, oblique fracture of the humerus or fracture of the outer por- tion of the head of the radius, the so- called chisel-fracture, resulting from the counterpressure of the external condyle against the outer margin of the head. The so-called "derange- ment interne," already mentioned as occurring in children, is regarded by many as an incomplete dislocation of the radius. These injuries were de- scribed previously under fractures. The rare backward dislocation of the radius results from a fall upon the hand with the arm outstretched. The head is palpable at the outer side of the olecranon; the arm is slightly flexed and pronated. Supina- tion, extension, and flexion are limited. The treatment is the same as for for- ward dislocation; traction upon the forearm with direct pressure upon the head, fixation for eight to fourteen days, and then motion. Operation is indicated if reduction is impossible. Several cases of outward disloca- tion have been observed. Loebker reports 2 instances in which the pa- tient, pushing a cart, was struck upon the back of the elbow by another cart approaching from behind; the arm was pronated and semiflexed. The head of the radius projecting outward in front of the external condyle is easily recognized on inspection and palpation. Pronation and supination are often only slightly limited. Loebker in his cases had to resect the head. In a few instances in which reduction was not attempted or possible there was a fair return of motion, only extreme flexion being prevented. Fracture of the ulna is a rather frequent complication of dislocation of the radius, as illustrated in Fig. Outward dislocation of the head of the radius with fracture of the ulna in the upper third. (Trendelenburg.) DISLOCATIONS OF THE ELBOW. 209 138. In this case the radial nerve was paralyzed. This combination is produced by direct violence upon the ulna, the fracture resulting first, and then the dislocation; it may he caused indirectly also by a fall upon the hand. The usual deformity of this combination is as follows, the ulna is commonly fractured in the upper third; on the radial side is a marked prominence in which the head of the radius can he felt; on the posterior surface of the ulna is a deep angular depression of the skin the point of which corresponds to the site of fracture and from which two lines diverge toward the head of the radius and toward the olecranon. The line joining the head of the radius and the olecranon is continued laterally over the external condyle. Even though the dislocation is not recognized or reduced, there is usually a fair return of function. The author has seen several cases in which only extreme supination and flexion beyond a right angle were impossible. The power of the hand and of the arm is almost normal. Treatment. — By reduction of the dislocation, which is the essential point, the fragments of the ulna are replaced during the manipulation and traction upon the forearm. The ordinary plaster splint will main- tain the bones in position. If the head of the radius is irreducible, resection may be necessary. The after-treatment is an important element in the management of dislocations of the elbow-joint. Most of the above forms of dislocation, except that of the head of the radius, require only a short enforcement of rest, as the ends of the bones, from their form, maintain to a certain extent the solidity of the joint. Passive motion should begin at the end of the first or, at the latest, the end of the second week; it may be aided by mechanical apparatus and should be continued for some time. The experience of discharging dislocations of the elbow as cured and having them return in the course of a few weeks fixed in a position of marked flexion is not unusual. The after-treatment, aided by massage, should be continued, therefore, as long as any inclination to ankylosis or cicatricial contraction with limitation of motion is noticeable. In some instances this may mean months. Vol. III.— 14 CHAPTER X. DISEASES OE THE ELBOW-JOINT. ACUTE SEROUS AND PURULENT INFLAMMATION OF THE ELBOW-JOINT. Acute Serous Inflammation. — Acute non-purulent inflammation with more or less serous exudation in and about the joint occurs in rheuma- tism and gonorrhoea. Rheumatic arthritis requires appropriate internal treatment; only the more chronic form with secondary stiffness is of surgical interest in being amenable to mechanical treatment. The general symptoms of inflammation of the elbow-joint are pain, dimin- ished by rest, increased by motion, and tenderness and -welling. Full extension and flexion are impossible on account of the pain even in milder cases. The joint is tender on pressure, especially at those spots in which the inflamed synovial membrane can be pressed against the underlying bone. If the swelling is great, the distended capsule bulges and conceals the normal contour of the joint. Although the periarticular swelling generally conceals the intra-articular, by careful palpation at the head of the radius and at the sides of the olecranon behind one can usually feel the tumor-like bulging of the capsule and obtain fluctuation. This symptom-complex of acute synovitis with periarticular swelling is not. characteristic for any particular affection, but may apply to rheumatic, gonorrheal, and syphilitic lesions as well as traumatic arthritis and joint diseases of nervous origin. To determine the etiology of the synovitis all the accompanying symptoms must be taken into account. Treatment. — The surgical treatment of the different forms of syno- vitis can be embraced in a few words. The rheumatic form, to pre- vent subsequent stiffness and contractures, requires massage, hot-water or sand baths, hot-air baths, passive motion. These measures are equally valuable for other diseases of the joint producing a tendency to ankylosis. Gonorrheal arthritis of the elbow is rare; here as in other joints it is inclined to produce ankylosis, partly by reason of the severity of the periarticular inflammation. That the gonococcus is the cause of the frequently obdurate inflammations is proved by a series of bacteriological investigations of the exudate. Of the milder forms of gonorrhoeal arthritis, many recover without any particular treatment except rest. If the process is protracted, aspiration may be advisable, and finally the injection of tincture of iodine (3 to 4 c.c), or carbolic acid (2 to 3 c.c. of a 1 per cent, solution). For such cases the "forced-heat" treatment is of value, in which uniformity of temper- *( 210) PURULEST INFLA MM A TION OF THE ELBo W-JOINT. 211 ature and persistence in its application are essential. The source of heat is immaterial; the temperature should be about 45° C. The elbow- is more accessible for such treatment than almost any other joint. One may use Quincke's stove-pipe appliance, as suggested by Krause, or according to Bier a wooden box, or the author's method of enveloping the joint in plaster and around this coiling lead pipe through which hot water is siphoned. [The Sprague hot-air apparatus is widely used in America in hospital and clinical practice. The sand-box can be used by the more intelligent poor in their homes to great advantage if they are properly instructed.] As in rheumatism and gonorrhoea, an inflammation of the elbow-joint may occur in the course of other general infections, e. r/., in the infectious diseases, scarlet fever, diphtheria, dysentery, sepsis, pyaemia, typhus, variola, puerperal fever, pneumonia, erysipelas, and osteomyelitis. As a rule, at the onset of effusion in these cases the treatment should be expectant; in the event of fever, marked redness, tenderness, or phlegmonous swelling, pointing to a seropurulent effusion, exploratory puncture is indicated, and if necessary incision, drainage, and irriga- tion. Syphilitic Arthritis. — Either in the pure serous or gummatous form syphilitic arthritis is rare except in children with congenital lues. The etiology of the first form, which corresponds more to a chronic hydrar- throsis, is easily overlooked in the absence of any history and accom- panying secondary manifestations pointing to the catise. The gum- matous form is more often mistaken for tuberculosis. In the event of other signs pointing to syphilis the diagnosis is not difficult, still in many cases we will require a bacteriological examination or even inoculation. Doubtful cases of this form of arthritis always call for a differential diagnosis ex juvantibus. In the case of children it is well to give sub- limate baths of 1 : 10,000 besides inunctions. A form of specific infec- tion termed syphilitic osteochondritis appears in early infancy in con- genital lues, and, according to YVegner, attacks preferably the elbow- joint. The epiphyses are loosened by a growth of granulation-tissue and become separated, giving the clinical picture of paralysis. The patient does not move the arms, so that they hang relaxed as if paralyzed. Acute serous synovitis resulting from injury, sprain, fracture, or dislo- cation, assumes the form of a chronic traumatic hydrops less frequently here than in the knee-joint. In general the elbow-joint has a greater tendency to adhesive inflammations, so that stiffness and ankylosis result more frequently than serous inflammation from trauma. The prophylaxis of such cicatricial stiffening of the joint was mentioned under Fractures and Dislocations. The less frequent serous synovitis requires rest and possibly injection of iodine. Purulent Inflammation. — Purulent inflammation, aside from the metastatic inflammations of the infectious diseases, is commonly the result of penetrating wounds of the joint and compound fractures; it may result from direct transmission of an osteomyelitic process in the forearm or upper arm, exceptionally from cellulitis. Purulent arthritis, 212 DISEASES OF THE ELBOW-JOIST. recognizable bv marked tenderness, fluctuation, redness, and inflam- matory swelling about the joint, and by high, constant or intermitting fever, demands energetic interference regardless of its origin. If the inflammation follows a perforating, punctured, incised, or stab wound, there is usually a profuse discharge from the wound mingled with synovial fluid. The arm should be elevated, and if necessary suspended vertically in a Volkmann splint. The wound if small should be enlarged and drained. As retention occurs easily in the numerous recesses of the elbow-joint, a counteropening should be made early, preferably on the posterior surface at the side of the olecranon. In most of the cases it is immaterial whether one uses an antiseptic— carbolic acid, salicylic acid, lysol, bichloride — or not in irrigating. The same treatment applies to purulent arthritis resulting from a compound fracture. If the suppuration is profuse and drainage still insufficient in spite of numerous incisions, the question of resecting parts of the bones to obtain free drainage arises, and how far such resection should be carried. It is self-evident that a total resection here is not indicated, or rather not necessary, as sufficient drainage can be obtained by partial re- section. Total resection, further, always presents the possibility of a loose joint. The removal of the lower end of the humerus is really the only proper procedure. The experience of v. Bruns in employing partial resection of the lower end of the humerus for the cure of anky- losis demonstrates that this form of resection gives the best functional results, and is equally applicable to purulent inflammation of the joint, the operation being performed through a lateral longitudinal incision or through the wound. The idea of an intermediary resection founded upon the old views of infection does not retain its former significance at the present time. The author resects when according to the course of the disease he considers it necessary — in other words, when the general infection and the local swelling and inflammation signify the retention of pus. CHRONIC INFLAMMATION OF THE ELBOW-JOINT. Of the chronic inflammations of the joint, except tuberculosis, brief mention will be made only of the gouty and deforming variety and the changes of neuropathic origin. Gouty changes in the elbow-joint may cause urates to be deposited in or about the joint. The severe forms of arthritis deformans are not very frequent in the elbow, but growth and thickening of the bone, although commonly not very extensive, may result from trauma, espe- cially intra-articular fractures. In such instances the superficial head of the radius may be felt as a broad mushroom-like bony ring. The synovial membrane may be increased in the form of villous and den- dritic growths similar to those characteristic of arthritis deformans after the chipping off of small portions of the joint-surfaces. In the advanced stages of arthritis deformans the pain produced by motion is best alle- CHRONIG INFLAMMATION OF THE ELBOW-JOINT. ■_>[:', viated by immobilizing with a circular splint. Chronic inflammatory changes in the joint of nervous origin accompanied by atrophy and hypertrophy may affect tin- elbow, especially in syringomyelia, which attacks the upper extremity by choice. The lesion consists in a hydrops of the joint, and extensive deformation of the articular ends with destruc- tion and hypertrophy of the bone. The diagnosis demands careful examination of the nervous system. In pronounced cases the abnormal mobility, marked hydrops, and the relatively slight pain denote the neuropathic origin, as first shown by Charcot. These lesions are appar- ently not trophic but of a traumatic nature, the severe grade of inflam- mation being due to the inability of the patient to protect the joint by reason of the anaesthesia or analgesia. An interesting instance was observed in the Thiersch clinic: there was analgesia of the right hand and forearm to the middle of the upper arm; disturbance of sensibility was slight; there was marked thermoana\sthesia; the articular ends of the bone were destroyed for about half an inch. Often attention was called to the onset of the disease by a surprising insensibility to external injury, such as burns, etc. In regard to the treatment of these chronic changes there is little to be said. Apparatus are used as in the case of loose joints (which see) to fix the joint. Operation is counterindicated. Free Bodies in the Elbow-joint,— Free bodies of traumatic origin were discussed under fractures, particularly under chisel-fracture of the radius. Those resulting from avulsion may give trouble by becoming wedged in the joint. The chipping off of fragments occurs rather fre- quently, but does not always lead to the production of free bodies. Why this is so is not known. The certainty that trauma is the cause of many free bodies has led many authors to believe that all free bodies are of such origin. This view is not tenable in the face of many observations excluding the possibility of trauma. Konig has demonstrated that frag- ments such as are usually found in the case of free bodies could hardly ever be produced by experimental violence. His view, based upon large personal material and the later observations of his assistant, Martens, is, that the majority of free bodies result from pathological changes in the bone, which he designates as "osteochondritis dissecans." It is possible that a slight injury may finally separate the diseased piece of the cartilaginous layer and so make it a free body. Barth, from his investigations, regards all free bodies as fragments by trauma, which latter may be very slight. Experiments on animals give no positive proofs for this view, but in most of the author's cases the free bodies were referable to an injury, happening usually in youth. Free bodies in the elbow are comparatively frequent; they consist chiefly of car- tilage; a few contain bone. Symptoms. — The symptoms of a free body, characteristic to a certain extent, vary according to its position. Bodies situated in the anterior pocket of the joint give, according to Kocher, a characteristic limitation of motion; full extension falls short by 20 to 30 degrees; sudden attacks of pain, the appearance of inflammation, pain on pressure in the fore- 214 DISEASES OF THE ELBOW-JOINT. part of the joint, the palpation of a resistance and crepitus are diagnostic. Bodies situated in the posterior supratrochlear fossa are commonly symptomless unless of considerable size. Fig. 139 shows a beautiful specimen of a free body in the posterior fossa, and Fig. 140 two small bodies in the anterior fossa of the same Fig. 140. Free bodv in the olecranon fossa. Two free bodies in the coronoid fossa. specimen; a defect in the cartilage is visible on the eapitulum which may be traumatic. The history is lacking. Fig. 141 shows a free body in the coronoid fossa, evidently of traumatic origin; the patient as a child, thirteen years ago, received an injury upon the elbow by a fall. At the present time the loss of motion is slight, extreme flexion and extension alone being limited; attacks of snd- Fig. ] den pain are rare ; the arm of ten feels numb. A growth of callus on the radius would indicate that the free body is referable to a chipping off of the radius thirteen years ago. Treatment. — If removal of a free body is indicated, the site of the incision will depend upon the posi- tion of the body. Incisions on the posterior surface for bodies situated in the olecranon fossa are naturally very simple, and the body easily reached. On the anterior surface the joint is less accessible. The incision is made to the inner side of the cubital artery and median nerve; the branches of the internal cutaneous are easily protected; the fibres of the pronator teres are separated and held by blunt retractors; the brachialis anticus lying beneath is then re- tracted and the capsule exposed and incised. To expose the joint at the head of the radius from in front for bodies lying to the outer side and in front, the incision is to the outer side of the biceps tendon; the fibres of the supinator longus are separated, the underlying radial nerve retracted, nun iid fossa. CHR ONIC INFLA MM A TIOX OF Til E E I H W-JOINT. 215 and the capsule incised. The results of operation are very good; as a rule the restoration of motion is complete. The operation should be entirely instrumental and the asepsis very thorough. Konig reports excellent results in his numerous operations for free bodies of the elbow. Tuberculosis of the Elbow-joint. -Tuberculous processes of the elbow- joint are more common in children, but are observed after the thirtieth and fortieth year; they are more frequently a local manifestation of gen- eral tuberculosis; women are affected more often than men. From the statistics of the Berne clinic, 16 per cent, of the patients were under ten years, 36 per cent, under twenty years, 19 per cent, under thirty vears, 19 per cent, under forty years. According to Konig, 25 per cent, were under ten years, 20 per cent, under twenty years, 12 per cent, under thirty years, 15 per cent, under forty years, 8 per cent, under fifty years, 14 per cent, under sixty years, 6 per cent, under seventy years. The point of origin of the affection with a slow onset and course is either the synovialis — primary synovitis, the rarer form, or the bone adjacent to the joint — primary ostitis, the usual form. In 137 cases Konig found 71 per cent, of the latter, 29 per cent, of the former. The primary osseous foci have certain points of predilection; according to Kummer and Oschmann, in 50 of their cases it was the olecranon, in 33 the external condyle, in 20 the internal condyle, and in 20 the lower end of the humerus. Symptoms and Course. — The course is usually slow; small osseous foci in the neighborhood of the joint mav remain latent for a long time or be manifested merely by circumscribed swelling and tenderness over the olecranon or the condyles, according to their position. Often the real inflammation of the elbow will be first noticeable after the bony focus has perforated into the joint. Not infrequently this follows a slight injury, the latter on this account being regarded as the cause of the disease. The joint-infection once established with effusion is recog- nizable by the evident protrusion of the capsule at the head of the radius and posteriorly at the sides of the triceps tendon; this is accom- panied by periarticular cedema, and later the spindle-form of the so- called "white swelling" gradually develops with atrophy of the muscles of the upper and forearm. With involvement of the synovialis the func- tion of the joint is more and more disturbed and limited. Motion, also pronation and supination, is moderately painful. If the synovialis is involved at the onset, the impairment of motion develops more gradually; only the greater excursions are painful; later, swelling and pain slowly increase. Fig. 142 shows a characteristic spindle-form deformity of tuberculosis of the elbow; the child had a simultaneous spina ventosa of the left middle finger; Fig. 143 shows the recovery after injection of iodoform. In the later stages of the process there is usually a tendency to the formation of abscesses and fistulas. The pure fungous form is much less frequent than the suppurating; according to Kosima, 53 per cent, of all cases result in fistulas. The fistulas are situated either upon the condyles or the olecranon or open upon the posterior surface between 216 DISEASE* OF THE ELBOW-JO I XT. the radius and ulna; gravitation abscesses develop secondary to those about the joint, advancing down the forearm. Extensive destruction of the capsule, ligaments, and cartilage gives rise to false mobility, the joint yielding to lateral movements, often with elastic resistance. Many eases of tuberculosis are not seen in the incipient stage, but "after a marked tumor has developed and the synovialis, bones, cartilage, and ligaments have become involved. Prognosis. — It is clear that in view of the great difference in the forma- tion and development of tuberculous processes a positive prognosis is Fig. 142. Fig. 143. Fungous tuberculosis of the elbow-joint, (v. Bruns.) lame cured by iodoform injection. (v. Bruns.; impossible. There is no doubt that tuberculous affections of this joint may recover without any treatment, or at the most with immobilization, in that, as in all such processes of recovery, a growth of connective tissue encloses the tuberculous granulations and replaces them. It is impossible to estimate how many tuberculous processes, which perhaps develop up to the stage of a hydrops, heal spontaneously. It remains therefore to consider the prognosis of the cases appearing for treatment in a more or less advanced stage. It is evident that those only slightly advanced, especially those in which the joint is still little involved, stand a better chance of recovery, both on account of the limitation of the process as well as the better general condition, than the fistulous cases with extensive CHRONIC INFLAMMATION OF THE ELBOW-JOINT. 217 involvement. All authors arc agreed that the prognosis as to life is good provided there are no tuberculous t'oei elsewhere. As to the function, the results vary enormously. As to the results of the various therapeutic measures, the views of many authors, although generally favorable, are not in accord. Treatment. — Of the different methods <>|' treatment extant, the author will describe the following: injection of iodoform; passive congestion; operative interference, extensive or slight; evidement, partial resection; arthrectomy; total resection. Iodoform is generally recognized as of unquestionable value in tuberculous processes, especially tuberculosis of the elbow. The exposed position of the joint allows of the injection of iodoform on all sides, and the joint is especially accessible in spite of the fact that its complicated form is not particularly favorable for the dis- tribution of the iodoform within. The method in general use at present is the injection of a 10 per cent, solution of iodoform in glycerin; in the Leipzig clinic an oil emulsion of iodoform is used. Although the manner of application is practically the same everywhere, a great difference of opinion exists as to which forms of the disease are indication for this treatment; some authors go so. far in conservative surgery as to employ injection in the widest extent possible; others advise early energetic operative treatment. For the incipient stage of "white swelling," as it is commonly seen in practice among the poorer classes, the treatment is somewhat as follows: For injection one needs a large needle and a graduated syringe to hold about 10 c.c; the skin being cleansed and sterilized, the needle is inserted into the joint at the most accessible points, at the head of the radius, at the side of the olecranon, or beneath the internal condyle. The needle should be inserted obliquely through the skin and then straight into the joint, so that the skin acts as a valve over the joint-wound. In children up to the fourth or fifth year, the author injects 3 to 4 c.c. at one spot or in several places; in older children the dose can be increased to 8 to 10 c.c. Slight movement of the joint aids distribution of the injection. The arm is then immobilized in a strip splint. At the end of twenty-four hours there is usually marked irritation about the joint and slight fever. The result of the first injection is watched quietly and the joint is left undisturbed for eight to ten days. If the reaction subsides, the injection is repeated in about fourteen days. By this simple method it is possible to limit the process by three to four injections so that it gradually cicatrizes and heals without recurrence. Fig. 143 shows a patient with the white swelling as represented in Fig. 142, recovering with good motion after injection of iodoform. If the process has advanced to the formation of cold abscesses, the con- tents of the latter should be aspirated and then the iodoform injected; fistulas if present may also be injected. Where the fistulas are multiple they should be closed during the injection to force the iodoform all through by pressure, v. Mikulicz in injecting fistulas uses a syringe with an olivary tip corresponding to the size of the opening, to prevent reflux of the emulsion. For fistulas as well as for the remaining forms of fungous inflammation, it is beneficial to inject the surrounding tissues 218 DISEASES OF THE ELBOW-JOINT. instead of the foci. If the fistulas are large, the iodoform may be retained by tamponing. As iodoform is impervious to the a;-ray, the results of injection can be controlled by the fluoroscope. Slight intoxication with psychical disturbances, etc., has been observed occasionally after injec- tion; death from such, however, is of rare occurrence. The injection of other antiseptics, such as a 3 per cent, solution of carbolic acid, cinnamic acid, etc., has been recommended, but has proved inferior to iodoform. Opinion varies as to which cases of tuberculosis of the elbow are suitable for the iodoform treatment; the author's experience up to the present time would indicate the value of first trying the iodoform treatment in all instances in which the disease is not far advanced; and in fact the obligation is to try it, according to the view of nearly all authors, in children, in whom a major operation is certain to cause disturbances in growth. If at the end of four or at the most six weeks the treatment gives no improvement, energetic measures should not be delayed or the period neglected in which minor operations still promise benefit. If the inflammation is the more frequent osseous form, the surgeon may confine himself here also at first to the iodoform treatment: but even in this case it is advisable, if the bony focus can be demonstrated posi- tively by the .r-rays or otherwise, to scrape out the focus in order to remove small sequestra. Before proceeding to the minor and major surgical operations of the joint, the treatment by passive congestion, as first applied by Bier in 1892, should be mentioned. Opinion is divided as to its results; in some instances it has enthusiastic advocates and has given excellent results; in others it failed completely. Its proper valuation lies between the two extremes, and to the author appears properly designated by v. Mikulicz, who regards the congestion method as an aid to iodoform treatment. The method consists in constricting the upper arm with a Martin rubber band applied over gauze; the constriction should be only sufficiently tight to check the venous flow. The hand and forearm are enveloped in a muslin or flannel bandage; the joint is left free. The region of the joint becomes cyanotic; the joint swells and becomes oedematous; the granulations and the fistulas swell and become glisten- ing and bluish. The congestion should be continued for fourteen to eighteen hours daily, and repeated if well borne. In several days the granulations are often covered with a thick eschar as in beginning necrosis. Occasionally the tuberculous process appears to grow worse during the first few days; soon after removal of the constriction the swell- ing subsides, however, motion becomes freer, and healing commences. Passive congestion has not been extensively applied to the elbow, so that a definite estimation of its value is impossible. It is certain that it often exercises a beneficial influence upon the pain, which diminishes rapidly and permits apparently of freer motion. There is no evidence to show that the application of congestion alone at the beginning of the disease can cure tuberculous inflammation. Failures are unquestionable ; sometimes the treatment is badly borne; if so, time should not be wasted in further attempts. Bier admits that in his experience the formation CHRONIC INFLAMMATION OF THE ELBOW-JOINT. 219 of cold abscesses took place first under the influence of congestion, a result which he regards as favorable. It has been already mentioned that in children the treatment should be as conservative as possible, and should begin with the injection of iodoform, possibly combined later with congestion. In adults partial or total resection is more appropriate. Surgical interference is more readily carried out on the elbow, in which the bones are easily felt, and in which the frequent primary osseous foci are easily determined by the .r-ray, than on other joints. Minor operations for the removal of carious spots in the bone, as by scraping, are here simple. Konig and Kocher, the two most enthusiastic advocates of operative treatment for tubercu- losis of this joint, recommend early incision and scraping of such carious foci. If small fistulas persist, it is advisable, after scraping out the foci, removing sequestra, and dusting the cavity with iodoform, to close the skin-wound in order to secure primary union and avoid the secondary infection which often complicates tuberculosis and retards recovery. If the process cannot be limited by such minor procedures because the joint-involvement has advanced too far, more comprehensive measures are necessary. At the present time the rules followed are different from those observed formerly, when in such instances total resection was employed according to the teaching of this or that school. Now the duty of the operator is to avoid every set scheme in resecting and to modify according to the nature of the case. For tuberculosis of the synovialis simple arthrectomy is often suffi- cient; the joint is exposed by one of the incisions to be mentioned later under resection, and the cavity opened so that it may be examined easily; all tuberculous granulations are removed with scissors and sharp spoon, and any diseased cartilage excised. By arthrectomy is meant the removal of the capsule and cartilaginous disks. Kocher regards extirpation of the capsule as the chief purpose of arthrectomy; as a rule he does not advance directly into the joint, but dissects around the outer surface of the capsule, frees the same and removes it en masse. The removal of portions of diseased bone will depend upon the conditions found on opening the joint. It will often be necessary in connection with arthrec- tomy to scrape out small spots* or do a partial resection ; a more or less complete resection will be unavoidable if the bones are involved exten- sively. For the details of total resection, see the following chapter. Konig gives the following statistics: complete resection — complete recov- ery, 54 per cent.; incomplete recovery, 8 per cent.; deaths, 38 per cent.; incomplete resection and Other treatment — complete recovery, 32 per cent.; incomplete recovery, 8 per cent. ; deaths, 61 percent. The func- tional results were as follows: in 45 cases with complete recovery follow- ing complete resection, in 40 of which he used v. Langenbeck's method, in the other 5 his own, there was 60 per cent, of recoveries with more or less motion and good power, 33 per cent, with ankylosis and satis- factory power, 7 per cent, with loose joint. Kocher obtained a good working arm and hand even for hard work in 64 per cent., and a capacity for only light work in 36 per cent. 220 DISEASES OF THE ELBOW-JOINT. Fig. 144. From these statistics no general conclusions can be drawn as to the advantages of the individual operations, although these data are the results obtained by experienced surgeons, and are the best up to the present time. At any rate, in spite of the good results of purely conser- vative methods there is no doubt that a broad field lies open for total resection in the case of tuberculosis of the elbow, and that the procedure is capable of giving good results. It is demanded for the severe forms with extensive fistulas and for those cases in which conservative treat- ment has failed either because the process has not reacted favorably to iodoform treatment or because, on account of the fungous form of the disease, the iodoform could not be distributed through the joint, the process advancing in one place while healing in another. Partial resection is always to be preferred to total resection where the process is limited. If, for example, on opening the joint the chief focus is found in the lower end of the humerus, resection can be limited to the cubital process; on the other hand, if it lies in the ulna, the upper ends of the bones of the forearm are removed and the humerus left as intact as possible. Even in partial resection modification is possible, so that it is impossible to give a uniform mode of procedure here. The author would mention further that in every partial resection and arthrectomy where the head of the radius is ap- parently intact, the joint between the head of the radius and ulna should be examined carefully, as tuberculous foci here are easily overlooked. The technic of incision of the joint given in the following chapter applies also to partial resection. As to the pros- pects of success attending the appli- cation of the procedures mentioned, nothing definite can be said a priori. In general one can advise the iodo- form treatment for incipient cases, eventually perhaps Bier's congestion method. For the more advanced stages the available reports point definitely to early operative interference in the form of arthrectomy, or partial or total resection. The danger of the much-dreaded miliary tuberculosis which occasionally follows other joint-operations is not to be anticipated with reference to the el bow- joint, for in this case, accord- ing to the experience of Konig and Ivocher, it is an extremely rare occurrence. In children one thing only can restrain the surgeon from resecting, namely, the disturbance of growth. Fig. 144 shows an x-ray picture of the arm of a patient aged eighteen years, upon whom total Arrested growth after reseetion of the elbow fourteen years previously. Youth aged eighteen years. CHRONIC INFLAMMATION OF THE ELBOW JOINT. 221 resection was done in the fourth year for tuberculosis of the elbow. The arm was markedly shortened, the bones, as manifest in the picture, considerably underdeveloped in thickness. Interesting is the crossed position of the ulna and humerus. The patient can move the elbow slightly; the hand is intact, but its power, like that of the entire arm, greatly reduced. From this it can be understood how great may be the disturbance in growth following resection. CHAPTER XI. OPERATIONS ON THE ELBOW-JOINT. Fig. 145. RESECTION OF THE ELBOW-JOINT. Indications. — Resection may be necessary for severe suppuration fol- lowing wounds of the joint or compound fractures, although, as has been indicated, modern asepsis justifies the most strenuous efforts to preserve the relations of the normal joint. If a severe phlegmonous inflammation of the joint occurs, and periarticular inflammation and suppuration in the joint cannot be checked in spite of extensive drainage, the sur- geon is compelled in such cases to perform a partial or total resection. In war resection is more frequently advisable and necessary for severe gunshot-fractures. Further, it may be required for the reposition of irre- ducible dislocations, as already dis- cussed, particularly resection of the lower end of the humerus as proposed by v. Bruns. For ankylosis of the joint resection is contraindicated on account of the danger of loose joint, except where the position of the arm is faulty or the attempt to improve the function is desired by the patient, partial resection being preferable, as in the event of failure the operation may be repeated. The results ob- tained by Wolff in treating cicatricial ankylosis and by v. Eiselsberg in the case of irreducible luxation without resection and yet with the production of good motion, are related in the corresponding sections. The most fre- quent indication for resection is the fungous form of tuberculosis of the joint, and the nature and extent of the operation will depend obviously on the extent of the process. All authors are agreed in advocating preservation of healthy bone con- sistent with removal of all diseased portions. Of the various methods of total resection, only those of v. Langenbeck, Oilier, and Hiiter will be described. In v. Langenbeck's operation the forearm is flexed and rotated until the olecranon points upward. The ( 222 ) Besection incision. 'After v. Langenbeck. i RESECTION OF THE ELBOW JOINT. ^2:', incision is made over the posterior surface of the olecranon, extending upward and downward about 2 inches in both directions. (Fig. L45.) The olecranon fossa is entered above the tip of the bone and the triceps split upward as far as the incision. The periosteum is peeled off with the soft parts, en masse if possible, beginning on the inner side, either with the forceps and bone-scalpel or bystretching it with the finger-nail and cutting the retaining fibres. On the posterior surface of the ulna it is easier to lift off the periosteum and soft parts en masse with the periosteal elevator. In loosening the tissues in the ulnar groove, the ulnar nerve should be guarded and pushed aside over the inner condyle with the soft parts. The attachments of the tendons and muscles and the internal ligament are then separated from the condyle. On the outer side the soft parts are pushed over the external condyle in the same manner, the ligaments and muscular attachments being lifted off en masse; by flexing forcibly the joint can be opened for inspection. All parts still tense are divided and the joint dislocated. It is easier to first saw off the low^er end of the humerus at the level of the condyles; the upper ends of the bones of the forearm are protruded, the soft parts held back with blunt retrac- tors, and the bones sawed off below the radioulnar joint — that is, beyond the head of the radius. From lack of space it may be necessary to remove the upper end of the forearm first. If the caries extends beyond the sawed surface, the foci are scraped out to sound bone. This com- pletes the operation as performed by v. Langenbeck; but Konig's demon- stration of the involvement of the synovialis in the process presents a further and important task in the removal of the entire capsule and all granulation-tissue, the latter recognizable by its glazed appearance. The joint should be cleansed thoroughly of all tuberculous tissue with forceps and scissors or scalpel and sharp spoon. The majority of operators then dust the joint with iodoform, suture and drain. It is best to remove the tourniquet before applying the splint, and to ligate any bleeding points. Konig applies the splint first and then removes the constriction; in his experience bleeding is slight. The arm is bandaged in semiflexion; strips as formerly employed by Esmarch are not neces- sary, as the ordinary dressing with or without the incorporation of wood or paper strips is sufficient to fix the arm. The latter is elevated and steadied with sand-bags or pillows; v.Volkmann's suspension splint is ser- viceable. A strictly subperiosteal resection, as emphasized by v. Langen- beck, is not regarded as essential at the present time; in some instances portions of the periosteum should be removed rather than leave any diseased tissues behind. On the other hand, where the bone is normal and the presence of certain bony points of support are essential for the subsequent function, the author leaves more than the periosteum; for example, at the epicondyles the soft parts are not separated off, but a flat disk of the bone is chiselled off with them to leave a firm base of attachment for the muscles. For the same reason it is important to preserve a part of the olecranon ; Kocher does this through the incision recommended by Oilier, first sawing off the head of the radius and then sawing the ulna from before backward, making a curved section 224 OPERATIONS ON THE ELBOW-JOINT. Fig. 146. and leaving the posterior part of the olecranon intact; an artificial sigmoid fossa is thus made. For several years he has sought to produce the same result by chiselling off the superficial lamina of the olecranon to which the triceps is attached; to do this, the incision is made to the inner side of the line given by v. Langenbeck. This modification of the resection is very important for extension; further, Kocher claims that it is an excellent means of preventing the forward dislocation occurring easily after resection. The so-called bayonet or Z-incision was first proposed by Chassaignac, later by Oilier, and is widely used. (Tig. 146.) The incision begins at the outer edge of the triceps and the inner border of the supinator longus, extends to the external con- dyle, bends sharply toward the tip of the olecranon, and is continued from there directly downward upon the olecranon. With the arm flexed at 45 degrees, the incision is deepened down to the bone; the oblique cut strikes the anconeus; Oilier sepa- rates this from the triceps tendon. The latter is detached with the periosteum from the ulna and drawn side; in dividing the capsule behind, the portion over the external condyle and the head of the radius should be left intact as far as possible. The capsule is now exposed on the inner side be- hind and beneath the internal condyle; the arm should not be flexed too much; the capsule on the posterior surface is excised and the joint opened by flexing forcibly. The anterior part of the capsule is removed with the scissors and the ends of the bones, easily accessible, are sawed off. The bilateral incision of Hiiter gives a good view of the joint, and is applicable both for total resec- tion for fungous inflammations as well as for partial resection. Hiiter incises first at the tip of the internal epicondyle, and from it frees the attachments of the muscles and ligaments; on the radial side he begins the incision a little above the point of the external epicondyle and continues it downward for about 3 or 4 inches; the lateral and annular ligaments are incised over the head of the radius, the neck laid bare with the knife and elevator, and the head removed with a pointed saw. The attachment of the capsule is put on the stretch by introducing the finger beneath it and the capsule divided in front and behind. The end of the humerus is now dislocated outward and sawed off. In like manner the ulna is protruded and, after subperiosteal elevation of the triceps insertion, its upper end is removed with the saw. Trendelenburg frequently chisels off the olecranon, completes the resec- tion of the joint and the removal of all diseased tissue, and then sutures the olecranon back in place. As to the after-treatment: Konig applies the fixation splint with the forearm extended; in fourteen days the stitches are removed; in four Resection incision. (After Oilier.) RESECTION OF THE ELBOW-JOINT. 225 weeks the arm is flexed, eventually under anaesthesia. The hand should be immobilized in supination. As soon as the wound has healed gentle passive movements should he begun. Electricity, massage, etc., are beneficial. Kocher emphasizes the importance of careful after-treat- ment, even to the slightest details, to prevent a loose joint or ankylosis. He tampons the cavity; in eight days the tampons are removed; in fourteen the wound is usually healed. The first position of the forearm in the splint after operation is very essential for its later conformation; any lateral or forward displacement must be avoided, as both positions favor the formation of a loose joint. To secure a fibrous covering over the ends of the bones, the latter are kept apart and brought into their normal position first at the end of from ten to fourteen days; this is supposed to prevent bony ankylosis. To favor the formation of the joint subsequent to operation, passive motion should not be commenced too soon, but rather the mobility of the joint in the normal direction ' If ■ 14 ~- guided by means of an apparatus. The latter should be applied as soon as possible, and consists of two sheaths to encircle the forearm and upper arm, from which two iron strips on the inner and outer sides connect at the elbow in an adjusta- ble hinge-joint that may be fastened at any angle. Instead of adjusting and fastening the hinge-joint, the forearm may be flexed by means of elastic bands attached to the two sheaths. Fitted with such an ap- paratus, the forearm can move only in a certain plane. The slight de- gree of active motion possible at first is rapidly increased by exer- cising; the muscles. The ends of the bones by their constant contact gradually conform to each other ; connective tissue forms between them and binds them more and more stably together. In a short time a firm and natural stability is acquired, so that the apparatus is superfluous and required only dur- ing heavy labor. In Kocher 's ex- perience the patient was not infrequently able to do heavy work later without the apparatus. One can understand this from the or-ray pictures of Kocher's cases, reproduced by Oschmann; in 25 cases of total resec- tion, 36 per cent, were able to do light work, 64 per cent, hard work. The prevention of a loose joint may be nullified by beginning passive Vol. III.— 15 Apparatus for lex - . i following I ion. 226 OPERATIONS ON THE ELBOW-JOINT. motion too early. In the event of a passively or, what is more unpleasant, an actively loose joint forming, the hand may be fairly fitted for light work by applying a permanent strip splint, such as the one designed by Socin, Bidder, and others. Fig. 147 is an illustration of a splint of this sort; the two sheaths encircling the forearm and upper arm are hinged at the elbow by means of the two iron strips, and can be held at any angle by tightening a nut at the joint. Ankylosis is quite as undesirable as a loose joint; often, however, it cannot be prevented. If the arm becomes fixed in semiflexion, the advisability of further operation is open to question. The possibility of a loose joint resulting from the second opera- tion and the consequent decreased usefulness of the arm can never be prevented with certainty. If the patient is compelled to do hard work, the surgeon is always justified in discouraging a second operation. The question of resection and its methods has been discussed in the foregoing chiefly with reference to tuberculosis, which is by far the most frequent indication for operation. The technic and treatment are appli- cable to all resections carried out for other purposes. In resecting for an irreducible dislocation, v. Brims suggests the use of Huter's bilateral incision; in like manner one may use this or that method of resection for a purulent inflammation of the joint. Injuries will demand an incision appropriate to the lesion, so that details are superfluous. Know- ing the above-mentioned methods for total resection, it is easy to select and modify a method for partial resection. The value of partial resec- tion for tuberculosis of the elbow, taking into account the frequency of the primary osseous form, has already been emphasized; it is ad- visable to use one of the incisions recommended for total resection to obtain a free view of the joint and remove all diseased tissue. For minor operations— synovectomy, arthrectomy — inspection of the joint makes incision unavoidable. For such inspection Tiling makes a curved incision, beginning at the radiohumeral articulation and carried in a curve upward above the olecranon so that the triceps is divided in its muscular portion. The incision ends below the joint-line of the humerus and ulna. The stump of the triceps is turned back and drawn downward ; the ulnar nerve is drawn out and retracted to the inner side ; the epicondyle is chiselled off and the joint opened. In this manner the joint can be viewed throughout. The capsule and synovialis are excised. The epicondyle is sutured back in place and the triceps reunited. Early motion is necessary to prevent ankylosis. Naturally by this incision one may perform any degree of partial resection. AMPUTATION AT THE ELBOW-JOINT. Where amputation is necessary for severe injuries of the forearm, it is preferable when possible to resect below the elbow-joint, leaving the attachments of the triceps and biceps intact, as the short stump thus obtained gives much better results. Amputation of the elbow may be necessary, however, in cases of complete destruction or severe LIGATION OF THE CUBITAL ARTERY. 227 injuries of the forearm, such as are common in the mechanical industries; also for extensive injury of the soft parts with more or less complete exposure of the hones of the forearm. Such extensive defects of the skin and soft parts may be covered in with Thiersch grafts or skin-flaps from the chest or abdomen; even here conservative surgery has its limitations, however. The preservation or amputation of the arm will depend upon the amount of damage to the vessels. In cases in which it is doubtful whether gangrene will occur or not, the operation may lie deferred until gangrene is evident. Old and feeble individuals should not be subjected to severe and long suppuration; amputation should be early. It is often indicated in septic processes, especially in the malignant form of diabetic gangrene, and in the latter instance should be done at once if the process appears to be progressive with high fever. Tn diabetic phlegmon, in which diffuse oedema often spreads rapidly up the arm, one can operate in the ©edematous area without fearing advance of the process in the oedematous stump, for the oedema precedes the bacterial invasion in the cellular spaces, as has been demonstrated by cultures. In the classical method of amputation the anterior flap is quadrilateral with base about an inch below the epicondyles; this quad- rate form is essential to cover in the broad projecting cubital process. The posterior incision is semicircular; the anterior flap is dissected off upward to the bone and retracted until the capsule is exposed. The joint is then incised, beginning at the head of the radius, and the lateral ligaments divided; the forearm is hyperextended, the attachment of the triceps divided, and the dissection of the posterior flap completed; the cubital artery, or the radial and ulnar if the branching was higher up, and the branches of the rete articulare are ligated. Instead of the anterior flap incision, one may use the circular incision with a cuff dissection of the skin to the level of the joint. Many advise removal of the cubital process, partly on account of the smaller covering required, partly for the removal of the synovialis; this is not necessary. The preservation of the cubital process is important for the application and stability of a prothesis. LIGATION OF THE CUBITAL ARTERY AND LOCATION OF THE NERVES AT THE ELBOW-JOINT. To ligate the cubital artery, locate first the cephalic, basilic, and median veins of the venous plexus; the cephalic vein runs on the outer side (the radial side) of the arm; the basilic vein on the ulnar; and the main branch of the median joins the two. A longitudinal incision is made in the elbow from \ to -V inch to the inner side of the biceps tendon. The median vein crossed by the incision is retracted; beneath the skin lies the semilunar fascia, running obliquely from the biceps tendon to the outer border of the fascia of the forearm ; directly beneath it lies the artery with its two small veins; the artery lies therefore between the biceps tendon on the outer side and the median nerve on the inner side. 228 OPERATIONS ON THE ELBOW-JOINT If the brachial artery divides higher up on the forearm than normally, the ulnar artery may lie upon the semilunar fascia; or twin arteries may be found beneath the fascia. The median nerve is easily found at the outer edge of the pronator radii teres and to the ulnar side of the cubital artery. The ulnar nerve lies superficially behind the internal condyle, palpable through the skin with the arm extended, as a thick round cord, and is not easily over- looked. The radial nerve, often damaged or torn in the same manner as the preceding nerves by trauma, such as fractures and dislocations of the elbow, is more difficult to expose. The incision should be made along the inner border of the supinator longus; the cephalic vein is pushed aside; on separating the fascia on the outer side of the biceps tendon the musculocutaneous nerve is exposed. The radial nerve lies beneath the supinator longus, which is retracted, and divides into a superficial and a deep branch at the outer side of the brachialis anticus. In opening the joint for drainage or operations at the head of the radius, one should always know the exact position of the nerves. CHAPTER XI I. MALFORMATIONS, INJURIES, AND DISEASES OF THE SKIN AND SOFT PARTS OF THE ELBOW AND FOREARM. The so-called "wing-skin" formation is apparently very rare at the elbow. The author found only 1 case in the literature. The patient illustrated by Fig. 14S had a symmetrical wing formation of the skin at the elbows, preventing extension beyond a right angle; flexion was Fig. 148. " Wing-skin" formation at the elbow. Man aged thirty years. free; beneath the skin could be felt a tense thin fascia. Muscular defects are combined with this formation; the lower half of the biceps and triceps is lacking. These muscular defects and the shortening of the fascia, producing wing-skin, are apparently referable to the same unknown cause. A child of the patient had the same peculiarity in both elbows, although not so markedly developed. This heredity apparently speaks against a conceivable purely mechanical cause — intrauterine pressure or adhesions. INJURIES AND DISEASES OF THE SKIN OF THE ELBOW AND FOREARM. Skin- wounds on the forearm, such as cuts, tears, bites, and contusions, are not without danger on account of the easy transmission of infection in and between the muscular interspaces, and therefore require careful ( 229 ) 230 MALFORMATIONS AND DISEASES OF ELBOW AND FOREARM. antiseptic and aseptic treatment; the edges of the wound should be excised and dirt and foreign bodies, such as fragments of glass, wood, etc., removed. In an exposed area like the elbow and forearm, injuries producing extensive defects in the skin are frequent. In the modern mechanical industries, in which the various kinds of machinery are con- trolled by hand, severe lesions of the skin and arm are not uncommon; the skin of the forearm is in some instances torn off like a cuff up to the elbow. Transmission appliances also, such as gearing and belting, are apt to produce such lesions. Burns often result in extensive destruc- tion of the skin. Recent wounds with more or less destruction of the skin, if they are not badly soiled, may be covered immediately with Thiersch grafts; the author has always seen excellent results, and not infrequently large surfaces completely covered in a short time, in from two to three weeks. Secondary defects, as from burns, heal quickly by grafting. The Thiersch method, as employed in the Leipzig clinic, the place of its discovery and development, is as follows: if the area to be treated is a defect following injury or a granulating surface from a burn, the author waits until the discharge and suppuration have ceased and the granulations appear active and healthy. If the granulations are spongy, soft, and exuberant, the pure silver nitrate stick is applied two or three times a week; if healthy, the surface of the granulation is cut off smoothly with a thin knife, or, better, scraped down to the superficial fascia with a sharp spoon. Bleeding is checked by gauze pads and the grafts pre- pared from the thigh with a razor. The grafts are applied upon the Fig. 149. Large skin defect due to spinning machine accident. iSclireiber.) wound and covered with silk, or, perhaps better, with tin-foil, and band- aged with gauze. In four or five days, or later if the discharge is slight, the first dressing is changed and a new one applied. In about ten days the wound is dressed with dry gauze or ointment (zinc ointment, etc.). In this manner large areas can be covered in a short time; subsequent contraction is usually slight. The accompanving illustrations (Fig. 140 and Fig. 150) show the excellent results of the Thiersch method, espe- cially the surprisingly slight contracture at the elbow, and the almost complete extensibility of the fingers, in spite of the fact that in this ISJURIES AM) DISEASES OF SKIS OF ELBO \Y AM) FOREARM. 231 injury almost the entire inner side of the arm and upper arm were skinned and had to be covered in. Slight oozing of Mood or much discharge from the scraped surface of the fascia sometimes prevents the grafts from taking. It is certain that the surface is irritated by the curettage and the discharge increased. To avoid the injurious effect of this dis- charge, the author has waited twenty-four or forty-eight hours after scrap- ing before applying the grafts, and has been pleased with the result. Fig. 150. Fig. 149, cured by Thiersch skin-grafting. The plastic-flap method is in the author's experience less advisable and more complicated than the Thiersch method. One may follow Krause's advice and use flaps from other parts of the body from which the subcu- taneous fat has been removed; these are adapted more for the leg and Fig. 151. Cicatricial contraction of skin and contracture of elbow. foot than for the upper extremity. They are valuable, however, for places such as the olecranon, exposed to external injury, and in which the Thiersch grafts are frequently found too delicate. The bridge-flap method consists in freeing a bridge of skin on the abdomen or thorax corresponding to the level of the forearm and pushing the forearm beneath it; the arm is bandaged in position and held for two to three 232 MALFOBMA TIONS AND DISEASES OF ELBOW AND FOREARM. weeks; the attachments of the flap are then divided. Cicatricial con- tractures are often unavoidable in case of extensive defects, even though the large areas can be covered in by flaps or grafts. Such contractures, according to their position, may produce very peculiar postures of the hand and forearm; Fig. 151 shows a cicatricial contracture at the elbow from a burn; extension was limited to 100 degrees. By transverse incision and transplantation extension was increased to 160 degrees; flexion was free. In order to overcome such contractures as far as possible operation is unavoidable. Gymnastic exercises may gradually produce improve- ment by stretching the cicatrix; nevertheless transverse incisions with forcible extension under anaesthesia and subsequent grafting are usually necessary. The incisions are modified naturally according to the direc- tion and extent of the cicatrix; and their effect can be heightened by implanting pedunculated flaps from the upper arm. Continuous exten- sion of the forearm, as advised by Schede, may also effect gradual stretching of the contracture; adhesive-plaster strips are applied to the front and back of the forearm and weights attached; by the continuous traction the skin of the upper arm is drawn down and its mobility and extensibility may be utilized for covering in the elbow. Such contrac- tures require protracted after-treatment to prevent recurrence. Inflammation and phlegmon often follow injuries of the forearm, but are more frequently transmitted from inflammation in the fingers, chiefly panaritium. In simple lymphangitis the red streaks of the lymphatics appear on the flexor surface, accompanied by secondary swelling and tenderness of the cubital and axillary glands; -the process subsides rapidly with rest and the application of wet dressings; Volkmann's suspension splint is very useful, the arm being elevated in the trough in the usual manner. Timely incision, drainage, and elevation of the arm are necessary for subcutaneous and deeper phlegmonous inflam- mations, either from a panaritium or from wounds of the forearm, to prevent the suppuration from advancing. If the inflammation extends to the joint, as happens infrequently, free drainage is indicated. Phleg- mon and secondary arthritis following acute osteomyelitis of the forearm will be considered later. As lymphangitis shows a tendency to follow the vessels, especially the cutaneous veins, in certain cases of severe infection one finds extensive thrombosis, chiefly of the superficial veins, the veins apparently containing purulent thrombi. The clinical picture of a pyiemia beginning with chills points to the vascular system as the source of infection in these cases of purulent thrombosis. Founding his hopes upon the good results obtained by ligation of the jugular vein in thrombosis of the lateral sinus, Trendelenburg sought in one case to wall off the source of the pyamiie infection by extirpating the thrombosed superficial veins, but the general infection had already advanced too far; the patient died. Miiller has recently operated upon such cases with success. The author will mention here only a few of the inflammatory diseases of the skin of the forearm and elbow which concern the surgeon. The DISEASES OF TENDOX SHEATHS OF ELBOW AND FOREARM. 233 true skin affections, such as psoriasis, herpes tonsurans, etc., do not belong in this text-book. Occasionally anthrax, which the author has opportunity to observe so often, is seen upon the forearm, especially in cattlemen: at the Leipzig clinic a butcher appeared who, after skinning an animal which had died of anthrax, had about twenty pustules <>n both arms; deep cauterization with the Paquelin cautery effected a cure. Of further interest to the surgeon is the infrequent occurrence of carci- noma on the forearm, as reported by Volkmann and others in the case of paraffin-workers, who often have chronic eczema on the forearm. The interrelationship of this carcinoma and the eczema, and indirectly of the occupation of distilling certain animal products, still requires explana- tion. INJURIES AND DISEASES OF THE TENDON-SHEATHS AND SYNOVIAL SACS OF THE ELBOW AND FOREARM. Tendons severed by wounds of the lower part of the forearm must be sutured; the suture methods will be considered more in detail in the chapter on Injuries of the Hand. It is self-evident that the disinfection and cleansing of wounds, particularly of the tendons, in this region must be strictly enforced, as union of sutured tendons requires complete asepsis. If suppuration occurs, the sutures break and the stumps of the tendons retract or become necrotic and slough. Secondary adhesions between the tendons and the adjacent structures following a purulent inflammation may be so firm as to be inseparable even by long-continued energetic mechanical treatment. The location and suture of the corre- sponding stumps naturally presuppose an exact knowledge of the anatomy. If the proximal stumps are strongly retracted, they must be sought through a longitudinal incision; bandaging the forearm from the elbow down with an elastic bandage is useful in pushing down the proximal ends into the wound. The peripheral ends are forced into the wound by flexing or hyperextending the hand, according as the flexor or extensor tendons are involved. As sutures the author uses only silk. At the end of ten or at the most fourteen days' fixation in the position affording the greatest relaxation of the sutured tendons, active and passive motion are begun gradually to prevent adhesion of the tendon at the point of suture to the adjacent tissues, and as far as possible to restore the normal mobility of the hand and fingers. The subject of inflammation of the tendon-sheaths, so important for the surgeon, is merely touched upon at this point, as tenosynovitis will be considered in detail in the chapter on the Hand, for most of the cases of inflammation of the tendon-sheaths are by transmission from the hand and wrist. The loose thin sheaths containing the tendons of the forearm allow the inflammation to spread diffusely in the forearm and penetrate into the muscular interspaces. The prevention of this deep inflammation of the forearm demands sufficient and timely incision and drainage. Tenosynovitis crepitans, or sicca, is an inflammation with 234 MALFOBMA TIONS AND DISEASES OF ELB W AND FOREARM. peculiarly characteristic symptoms and involves by choice the tendons of the forearm; the tendon-sheath deposits fibrin on its inner surface; movements of the fingers and hand are painful; the hand laid upon the tender spot feels a friction-crepitus, like crackling leather, which, heard with the stethoscope, sounds like the rale of dry pleurisy; it is caused usually by overexertion, especially by unaccustomed handwork. The tendons upon the posterior surface of the forearm, particularly the exten- sors of the thumb, are the ones more commonly affected, and of these the abductor pollicis and extensor pollicis brevis with surprising fre- quency. The inflammation subsides in a short time with rest and com- pression by means of wet dressings. Inflammation of the synovial sacs of the elbow affects chiefly the olecranon bursa and the bursa beneath the biceps tendon on the tuber- osity of the radius. Other bursa? in this region are small and not con- stant. Bursitis olecrani may occur as an acute inflammation following injury, and is characterized by a circumscribed painful and reddened swelling on the posterior surface of the olecranon; the sharp demarcation of the swelling at this point, the pain, the non-involvement of the joint recognizable by the existence of its normal mobility, signify disease of the bursa. Milder inflammations subside under wet dressings; puru- lent forms demand incision and drainage or the excision of the bursa. The discharge of mucoserous fluid from a bursa opened by trauma may be mistaken for an injury of the joint. Hygroma, the chronic form of bursitis, occurs as an occupation- disease at the olecranon as in many other parts of the body; it usually affects miners working in pits, tanners, or coopers, in whom, from the nature of their work, the olecranon is exposed to frequent irritation. It is best to excise the bursa and obviate the recurrence which is apt to take place after simple incision. The bursa may become tuberculous exceptionally or, when associated with gout, be the seat of uric-acid de- posits. In both instances it should be excised. Hematoma resulting from trauma is evidenced by an elastic tumor with the springy resistance of a rubber ball; it usually subsides spontaneously. Exceptionally one finds a small bursa beneath the triceps tendon, but it has no more signifi- cance than those occurring upon the epicondyles. The bursa lying deep beneath the biceps insertion upon the tuberosity of the radius is usually small ; it is hard to verify a diseased condition on account of its deep situa- tion. Sudden contraction of the biceps may cause hemorrhage in the bursa, evidenced by an elastic fulness and swelling of the sac; pain at that point on the radius, slight functional disturbance, and sensitiveness on rotation, signify disease or injury of the bursa. INJURIES AND DISEASES OF THE VESSELS OF THE ELBOW AND FOREARM. The cubital, ulnar, and radial arteries are usually sought and ligated at the point of injury in trauma of this area; ligation at a point of choice DISEASES OF VESSELS OF ELBOW AND FOREARM. 235 proximal to the site of injury is required only exceptionally. Formerly the more general employmenl of phlebotomy with the arterial lance exposed the cubital artery to frequent injury; if in opening the median vein the fleam struck the cubital artery at the same time, it led occa- sionally to the formation of an arteriovenous aneurism, a sacculated cavity communicating with the median vein and the cubital artery. Venesection, formerly so frequently used and regarded as possessing a life-saving power even in the most diverse general diseases, particularly the infectious diseases, is little employed at the present time. With tin- modern technic of incision with scalpel and forceps, damage to the cubital artery is scarcely known; the operation is facilitated by slightly constricting the upper arm until the venous current is checked, the arterial flow being undisturbed; the vein, easily seen beneath the skin, is then opened under local anaesthesia and the flow of blood allowed or checked, as desired. In adults 500 c.c. or more may be withdrawn without danger; if the flow is hindered by clotting, slight movements will stimulate the circulation; suture is usually unnecessary. After removing the constriction immobilization in a simple dressing checks the flow. Naturally the operation must be aseptic. Arteriovenous aneurism or aneurismal varix is, as related, a sac communicating with the median vein and cubital artery to which the pulsation of the artery is communicated. The diagnosis of this formerly not infrequent disease is not difficult; the same applies to the treatment, which consists in the excision of the sac and double ligation of the artery and vein. Aneurism of the arteries is rare in the forearm. The veins of the elbow are of interest on account of their being frequently incised for the infusion of salt solution. The most useful and more advisable method, namely, of subcutaneous injection, will only be replaced exceptionally by infusion into the vein in those instances in which it is necessary to inject a large amount of 0.9 per cent, salt solution rapidly into the body. On account of its superficial and accessible position the median vein is well adapted for infusion as used after severe hemorrhage; a fine canula is introduced into the vein and the solution allowed to flow slowly and guardedlv under slight pressure. The temperature should be between 39° and 40° C. [100° to 115° F.]. Diffuse dilatation of the vessels, a disease of the vascular system of the forearm, has been described by a few authors, but its etiology and nature are still unexplained; it is apparently an aneurismal dilatation of the arteries and veins; arterial pulsation may be transmitted directly through the widened capillaries to the veins. If the deep vessels are much involved, the angiomatous formation may extend through the entire arm, as observed in the case of Andry's and of the author's. In Andry's case there were motor, sensory, and vasomotor disturbances in the arm. The disease dated from early youth, possibly congenital; the arm when amputated showed the muscles, nerves, and even the bones changed by the angioma. In the author's case the radius was similarly dilated as bv a diffuse tumor. 236 MALFORMATIONS AND DISEASES OF ELBO W AND FOREARM. INJURIES AND DISEASES OF THE NERVES OF THE ELBOW AND FOREARM. TENDON-TRANSPLANTATION. Fig. 152. In the section on Fractures and Dislocations the author has frequently referred to the lesions of the nerves produced by displacement of frag- ments or by direct trauma. In supracondyloid fracture and T- and Y-shaped fractures of the lower end of the humerus, the median nerve is occasionally crushed or torn at the elbow; in fracture of the head of the radius and the external condyle the radial nerve may be involved; in injuries of the internal condyle and epicondyle the ulnar nerve may suffer. By incised or puncture- wounds or extensive laceration of the soft parts, the nerves may be divided at many points. The frequency of such injuries is governed by the amount of protection afforded the nerve by its situation; for example, the superficial position of the ulnar nerve in the groove behind the internal epicondyle is the reason for the frequent injury of the nerve at that point. The symptoms of paralysis are complete or incomplete, according as the nerve is completely lacerated and divided or only slightly contused. Injuries of the Radial Nerve. — The motor fibres of the radial nerve supply the extensors of the hand, the supinator brevis and longus, the extensors of the first phalanges of all the fingers, and the extensor of the terminal phalanx of the thumb. In paralysis of the radial nerve the hand is pronated, hangs limp, and cannot be raised; the fingers can- not be extended; if the first phalanges are held extended, the patient is able to extend the second and third phalanges (ulnar nerve innervation). On account of the drooping of the hand the flexors supplied by the me- dian nerve are impaired, so the condition simulates weakness in the region of this nerve; this apparent paralysis is overcome by extending the hand of the patient. Ab- duction and adduction of the hand are also impaired. The sensory disturbances follow- ing injury of the radial nerve are not so con- stant as the motor; it has been proved in numerous instances that the disturbance of sensibility in the skin area supplied by the radial may be slight or absent even after complete division of the nerve, as conduc- tion is immediately restored through anastomosis with the ulnar or median ; exceptionally this vicarious conduction begins immediately ; sometimes the disturbance is not compensated for several days. If the compensation is absent for a longer period, one can often demonstrate a gradual diminution in size of the anaesthetic area, sensibility returning slowly from the periphery. The zone farthest removed from the region External cutaneous nerve. Area supplied by the radial nerve on the outer side of the hand. DISEASES OF NERVES OF ELBOW AND FOREARM. 237 of the ulnar and median, and so most difficult to supply, remains insen- sible for the longesl time; this is the region upon the dorsum of the hand between the first and second metacarpals, indicated in Fig-. 152 by the cross-lines. The radial nerve divides in front of the external condyle into a deep and a superficial branch; the deep branch perforates the supinator brevis, passes around the neck of the radius, supplies the extensor mus- cles of the forearm, and sends the posterior interosseous as far as the capsule of the wrist-joint. The superficial branch approaches the radial artery below the elbow, covered by the supinator longus, courses along the outer side of the forearm to the wrist, and there supplies the skin on the dorsal side of the hand in the area indicated in Fig. 152. The degree of disturbance varies according to the involvement of the radial nerve as a whole at the elbow-joint, or only in one of its branches in the forearm; lesions of the deep branch produce paralysis of the extensor muscles of the forearm; lesions of the superficial branch, more or less complete anaesthesia of the area indicated. Suture of the radial nerve (musculospiral) in the upper arm is very simple, as it has consid- erable solidity at that point; suture of the branches beyond its division is more difficult; in the lower half of the forearm suture is no longer necessary, as the nerve after giving off its muscular branches at that point has no important function to fulfil. If the restoration of conduction is impossible or not obtained by suturing, the patient may be benefited by an apparatus fixing the hand and first phalanges and artificially flexing and extending the fingers. Among others, Heusner describes an apparatus consisting of a sheath which, on the flexor surface of the arm, covers an iron bracelet and envelops the hand and forearm to the fingers; the wrist is held slightly extended; the metacarpal joint of the thumb is left free; upon the dorsal side of the sheath run four elastic cords, connecting with broad elastic bands, which are applied like cuffs about the bases of the proximal phalanges. These traction-bands run under leather covers and hold the proximal phalanges extended. The hand is thus capacitated for light work. Even a simple celluloid sheath, fixing the forearm and the hand extended, increases the usefulness of the hand. Injuries of the Median Nerve. — The injuries most frequently demanding suture of the median nerve are incised and stab-wounds on the flexor side of the forearm above the wrist. The median nerve passes down the arm in the internal bicipital groove in front of the brachial artery, above the elbow lying to the inner side, then passes beneath the pronator teres and palmaris longus to the middle line of the forearm, whence it courses between the palmaris magnus and flexor sublimis toward the hand, passing with the tendons of the fingers beneath the transverse ligament of the wrist to the palm. As motor nerve it supplies all the muscles on the flexor surface of the forearm except the flexor carpi ulnaris and a part of the flexor pro- fundus, which are supplied by the ulnar; also the abductor pollicis, flexor brevis, and opponens pollicis, and either two or three of the lumbricales. 238 MALFORMA TIONS AND DISEASES OF ELBO W AND FOREARM. It is the main flexor of the hand and fingers. Only a small part of the flexors is supplied by the ulnar. The apposition and flexion of the thumb and the pronation of the hand also depend on the median; so in lesions of the nerve full flexion of the hand and fingers is impaired, the movements of the thumb are severely compromised; as the adductor supplied by the ulnar is the only active muscle, the thumb is extended and adducted, lying in the same plane with the other fingers, as in the so-called "ape-hand." The sensory disturbances comprise the area indicated in Fig. 153; the extent of the area is not always the same. Injuries of the Ulnar Nerve.— Lesions of the ulnar nerve produced by the same forms of trauma which affect the median are not infre- quent; the site of injury is commonly the ulnar groove at the elbow, where the nerve is compressible against the underlying bone and exposed to external forces by its superficial position. Fig. 153. Fig. 154. a Area supplied by the median nerve: a, dorsum ; b, palm. a b Area supplied by the ulnar nerve: a, dorsum; b, palm. The nerve runs in the groove between the internal epicondyle and the olecranon, perforates the flexor carpi ulnaris, and proceeds between this and the flexor pro- fundus at the inner side of the ulnar artery to the wrist. Above the wrist it divides into a volar and a dorsal branch; the latter is the sensory nerve for the back of the hand. ( Fig. 1 54. ) The volar branch passes over the transverse ligament at the side of the pisiform bone to the palm and divides into a superficial and deep branch, the former supplying the skin, the latter the muscles of the little finger and one or two lumbricales, the volar and dorsal interossei, adductor pollicis, and deep head of the flexor pollicis. Ulnar paralysis is mani- fested by paralysis of the interossei, which flex the proximal phalanges and extend the middle and terminal phalanges of all the fingers except the thumb. In protracted paralysis the action of the unaffected antago- nists produces the so-called "claw-hand;" the proximal phalanges are hyperextended, the middle and terminal phalanges are flexed. The spreading ability of the fingers produced by the interossei is also lost. diseases <>r xehves or ELBOW AND FOREARM. 239 The little finger cannol be apposed to tin- thumb opponens minimi digiti; or abducted abductor minimi digiti. It is difficult to verify loss of adduction of the thumb; slight weakness of flexion of the hand depends upon paralysis of the flexor carpi ulnaris. If the nerve is severed by a Stab, incised, or puncture wound, there is no question as to suture being indicated. If the paralysis is produced, however, by pressure, as by injudicious application of the Esmarch or by compression of the ulnar in the ulnar groove by blunt violence, or if the radial is affected in a fracture of the head of the radius, the determination of the nature and extent of the injury is often impossible, and the prog- nosis can only be given with probability. In many instances of subcu- taneous injury it is difficult to determine between division of the nerve and severe contusion, as the latter can completely inhibit the function of the nerve. If the nerve is severed, reaction of degeneration appears in the muscles supplied by the nerve in fourteen days; exposure and suture of the nerve are then indicated. If, on the other hand, no degen- eration-reaction is evident and the paralysis continues unchanged for weeks, the question of operation is difficult. If the paralysis increases, the surgeon should convince himself of the nature and extent of the injury by examination. There are cases, however, giving a doubtful prognosis at the outset, in which the paralysis gradually decreases and disappears in the course of months without operation. With the modern technic it is better not to wait too long, but to operate. The importance of asepsis is self-evident; the ends of the nerves are sought, and if irregular are trimmed up, and approximated. In the Leipzig clinic sutures of fine silk are always used. The suture is introduced into the sheath of the nerve a short distance from the end, passed along underneath the sheath, and out again about \ inch above, turned back, and passed in the same manner but in the opposite direc- tion through the sheath of the other stump. Several sutures are intro- duced thus around the nerve, and a retention suture passed through the stumps farther from the ends. In applying the dressing, the hand should be fixed so as to relax and prevent any tension upon the sutures. The hand should be immobilized for three weeks, and then motion begun slowly. The results of suture vary. Full recovery of motion and sensation is unquestionably possible in cases of complete division of the nerve. The time varies in which motion returns after suture, depending upon how soon the latter follows the injury. Some statistics give the time as a few days or weeks; the usual period, however, is decidedly longer, the first motion commonly appearing at the end of six months, completely in nine to ten months. During this period atrophy of the muscles should be prevented by electricity, massage, baths, etc. With the return of conduction movement is first possible indirectly through the will-impulse; later the nerves react to electricity. If a portion of the nerve is lacking in the forearm or at the elbow, it is harder to know what procedure to advise. The proposal to approxi- mate and unite the separated ends of the nerves by excising a piece of 240 MALFORMA TIONS AND DISEASES OF ELB W AND FOREARM. Fig. 155. J bone, as employed by Lobker and v. Bergmann in the forearm, in the upper arm by Trendelenburg, is applicable only in exceptional cases. If the nerves cannot be stretched, they should be united by making lateral flaps turned back from the ends of the stumps. (Fig. 155.) Experiments have been made on animals to prepare a path for the growth of the nerve by various means — decalcified tubes of bone, nerve-sections from other animals, strands of catgut — but any judgment of these methods and their results is impossible at the present time. The rare dislocation of the ulnar nerve may result from trauma. Schwarz collected 10 cases. The cause is forcible extension of the arm. As the dislocation known as "snapping" of the ulnar is liable to become chronic, it is necessary to fasten the nerve in the ulnar groove; the triceps tendon has been sutured over it, or a muscular flap, freed from one of the muscles attached to the internal epicondyle and drawn backward and sutured over it. The neuritis occasionally accompany- ing this dislocation is very disagreeable. Tendon-transplantation as a method for partial res- toration of the function of paralyzed muscles has be- come generally known only in the last ten years. In 1882 Nicoladoni first recommended transplanting the tendons of par- alyzed muscles to sound muscles to overcome certain paralyses of the leg, such as frequently follow cerebral paralysis in children. Pre- viously the peripheral end of a tendon had been sutured to an ad- joining sound tendon, in cases in which, following division of the tendon, the ends could not be reunited with good results. In this manner Krynski helped a case, in which he could not find the proximal Plastic operation for nerve-suture. Fig. 156. Fibrosarcoma of the median nerve, (v. Bruns.) end of the flexor tendon of the middle finger, by implanting the distal end into the adjoining tendon of the index finger. Drobnik did a trans- plantation after the manner of Nicoladoni in the forearm of a girl affected with paralysis of the extensor communis, extensor carpi ulnaris, the interossei, and abductor pollicis, in the following manner: He split the extensor carpi radialis longitudinally and sutured- the inner portion of the proximal stump to the upper surface of the tendon of the extensor CONTRACTURES AT THE ELBOW. 241 communis. In two weeks the patienl could open her hand and gradually learned to grasp lighl objects. Such transplantation in the forearm will never be so applicable to the complicated movements of the hand and fingers as it is to the leg; nevertheless, there are eases, as shown by more recent observations and results, in which this treatment is beneficial in appropriate instances of paralysis of individual groups of muscles, and particularly of paralysis of those supplied by the radial. Fibroma, occasionally multiple, and sarcoma occur in the nerves of the arm. (Fig. 156.) Neuralgia in the arm is rare. Paralyses or spasms in the muscles of the forearm or the hand of central origin do not belong in this section; in some instances slight improvement has been effected by means of mechanical apparatus, hut the results are insig- nificant. Improvement from the regular use of gymnastics, electricity, massage, and baths has been observed frequently. CONTRACTURES AT THE ELBOW. Fig Dermatogenous contractures and their treatment were discussed under Wounds and Defects of the Skin. Contractures of nervous origin from paralysis, aside from the forms related in the preceding section, are not amenable to surgical treatment. Myogenic and tendinogenic contractures are more amenable to orthopedic treatment combined with massage and exercises than to operative in- terference (tenotomy). In all injuries the prevention or prophylaxis of con- tractures is most important. If al- ready developed, they may be over- come sometimes by excising the cicatrix, or the tendons may be lengthened by tenotomy and suture of the stumps in the same manner as indicated in Fig. 155 for the suture of the nerve. Tenotomy may be necessary for flexion contractures of the fingers if the nails cut into the palm and produce pain and ulcera- tion. Myogenic contractures can result from inflammation and phlegmon in the forearm; from contusion; from fractures. In the latter case the cause may be not the fracture itself, but the constriction of a tight splint, the resulting stasis and insufficient nourishment leading to the destruction of the muscle and subsequently the so-called ischemic contracture. The danger of such improper treatment was emphasized Ossification of the biceps tendon following injury of the elbow. 1 See section on Contractures and Ankylosis of the Hand. Vol. Ill— 16 242 MALFOBMA TIONS AND DISEASES OF ELB W AND FOREARM. under Fractures, and the frequent occurrence of gangrene of the arm from improper splints was mentioned. An affection at the elbow usually mistaken for myogenic contracture is the not infrequent ossification of the biceps tendon, as indicated in Fig. 157. Sudeck has seen such cases following injury. The disturbance of motion is usually rather marked. The growth is attached to the bone by a pedicle. Berndt regards the periosteum as the origin of this ossification of the muscle, as he found a connection between the two in every case. On palpation a firm resistance is felt in the elbow which is usually diagnosticated as callus. Whether or not extirpation would produce improvement has not been sufficiently demonstrated by experience. CHAPTEE XIII MALFORMATIONS OF THE BONES OF THE FOREARM. Complete absence of the forearm has already been discussed. Of the congenital defects of the bones of the forearm, the author will describe briefly total and partial defect of the radius. In 1895 W. Kiimmel collected Fig. 158. Congenital hy] 68 cases of this sort; in nearly half of the cases the defect involved both the radius and ulna. Certain concurrent and almost typical manifesta- tions of inhibited development in the arm concerned point to the existence of such a defect; the thumb and its metacarpus are often lacking. In (243) 244 MALFORMATIONS OF THE BOXES OF THE FOREARM. the wrist the carpal bones are wanting on the radial side. In the forearm the radial group of muscles, the supinators, and the muscles for the thumb are absent. Combined with this there may be an abnormal condition of the biceps in the absence of the long head; the bicipital groove on the humerus may also be wanting; motion at the elbow-joint is frequently limited. Partial defect of the radius, usually of the lower end, is accompanied by corresponding anomalies in development, as in the case of total Fig X-ray of Fi defect. Fig. 158 shows a hypoplasia of the radius with the characteristic position of the hand, seen also in cases of total defect. The thumb is evidently backward in development. The x-ray picture Fig. 159 shows the retarded development of the radius and of the thumb, compared to that of the ulna and the other fingers. MALFORMATIONS OF THE BONES OF THE FOREARM. 245 Congenital defecl of the ulna, much less frequent than that of the radius, is usually partial, and may affect the upper or the lower end; it is often accompanied by defects of the fingers and of the metacarpal and carpal hones on the ulnar side. The diagnosis, easily established hv palpation, is made in detail with the .r -niv, as shown in the picture of a defect of the ulna. (Fig. 160.) Fig. 100. Congenital defect of the ulna. Etiology and Pathogenesis. — The action of adherent amniotic bands cannot be disregarded in many instances, particularly as small cicatricial depressions are sometimes recognizable at the lower end of the forearm as evidence of such alteration. The heredity in other cases points more to embryonal maldevelopment. Treatment. — Treatment is directed chiefly against the abnormal posi- tion of the hand produced by the deformity. The hand is sometimes deflected toward the affected side and flexed strongly if the muscles are defective. For such contractures correction is attempted by manipula- 246 MALFORMATIONS OF THE BONES OF THE FOREARM. tion or by means of a splint. Marked muscular contraction will often require tenotomy, especially of the flexors or extensors of the wrist, according to the position of the hand. The tendons of the fingers should be preserved if possible. The opposite treatment is required for those forms of congenital defect of the radius in which the wrist-joint is compromised in its function by a relaxed condition. In such instances, if it is not desirable to use sheath apparatus, the wrist may be fixed with pegs passed, according to Bardenheuer, through the lower surface of the ulna and the carpal bones after incising the joint. Similar deformities of the hand may be acquired in rare cases from unequal growth of the bones of the forearm. If, for example, the growth of the radius is retarded by osteomyelitis, the ulna pushes the hand into a position of radial adduction. In a case of this sort Oilier corrected the deformity by chondrectomy, that is, by resecting the lower epiphysis of the ulna. PLATE V. FIG. i. Fracture of Radius; marked Angular Displacement. (Stimson. FIG. 2. Fracture of Radius and Ulna in Middle Third, showing So-called "Hammock Curve." iSolley.) CHAPTER XIV. INJURIES OF THE BONES OF THE FOREARM. FRACTURE OF THE SHAFT OF THE BONES OF THE FOREARM. The ulna and radius are in contact at the ends, but between the shafts a space exists in which is stretched the interosseous ligament. The articulation of the head of the radius with the upper end of the ulna allows the radius to be rotated in pronation and supination around an axis extending from the head of the radius to the middle of the lower end of the ulna; during rotation the interosseous space is narrowed or widened, an important fact in the treatment of fractures. Fracture of both bones of the forearm is a frequent injury. The cause is usually direct, a force striking the forearm from the side, as a blow, pressure, crushing, etc. ; indirect violence, such as a fall upon the hand, is a less frequent cause and commonly affects the lower third. The fracture is relatively frequent in children. The weakest part of the radius is its middle; of the ulna, the lower third. If the violence is direct, the bones usually break at the same level; in 92 cases Oberst found the break at the same level in 50, in 31 the fracture of the radius was higher; in 11 that of the ulna higher; the lower third and junction of the lower and middle thirds were affected in 52; the middle third in 36, the upper third in 94. Infraction is said to occur rather frequently in the forearm, presumably with marked angular inflexion. The conception of infraction in such instances is much too broad; the avray shows that almost all these apparent infractions are transverse fractures with little or no displace- ment; infraction is common only in children up to the twelfth year (green-stick fracture). The line of fracture is usually transverse; less frequently oblique, or a longitudinal fissure or spiral; there may be no displacement of the fragments. If extensive damage of the soft parts occurs as a result of marked violence, the displacement of the four fragments may be con- siderable. The direction of the displacement depends upon the direction of the violence, the weight of the arm, and to a less extent upon muscular action. Symptoms. — The symptoms vary according to the form of fracture. Where the displacement is slight, the diagnosis depends upon the swell- ing, localized fracture-pain, and false motion. Crepitus is obtained only by forced motion. The hand of the affected arm is supported by the other hand; when held thus, one not infrequently observes the angular deformity at the point of fracture produced by gravity, even where the (247) 248 INJURIES OF THE BONES OF THE FOREARM. displacement is slight, the so-called "hammock curve." The inflexion of the forearm may form an angle opening inward or outward, accord- ing to the direction of the force. In view of the numerous variations in the position of the fragments observed in fractures of the forearm, it seems improbable that muscular action, as claimed by many, has any great influence upon the position. Prognosis. — The prognosis depends partly upon the degree and form of displacement, as the latter may prevent proper coaptation of the frag- ments. If in the common form of fracture, namely, with the fracture- line at the same level in both bones, the callus is very thick, even if the Fig. 161. Fracture of both bone rm with marked displa< (Trendelenburg.) displacement is slight, pronation and supination may be impaired. If the callus of the two bones grows together (Fig. 163), forming a synos- tosis, rotation may be checked completely. If the fragments are greatly displaced, so that the ends are widely separated laterally, as shown in the x-ray picture (Fig. 161), the lower fragment of the radius is almost apposed to the upper fragment of the ulna, so that improper union and functional loss occur very easily. In addition to this lateral dis- placement the fragments often overlap each other and the forearm is shortened. (Fig. 161.) The displacement may be such that the four fragments converge and become approximated, or diverge and become widely separated after the interosseous ligament is torn. The lower FRACTURE OF THE SHAFT OF THE BONES OF THE FOREARM. 249 fragments may be supinated or pronated more than the upper. All these displacements are significant for the prognosis, as union in an abnormal position may produce various disturbances of motion. Multiple fractures may occur in many forms (Fig. 162); in these cases coaptation of the fragments is extremely difficult. The callus formation mentioned above cannot be held responsible for the impairment of motion in all cases, v. Volkmann pointed out that the hand often remains pronated and cannot be supinated. If the callus Fig. 1()2. Fig. 163. Multiple fraetun Fracture of both bones of the fore- arm united by a bridge of callus, (v. Brims.) is supposed to cause this impairment, it is not clear why supination, by which the bones are separated and not approximated, should be limited. Other factors must be concerned. Konig attributes this limitation to the fact that union often takes place with the hand and the lower fragment pronated, while the upper fragment is supinated, so that the fragments unite rotated upon each other. The supination of the hand is thus 250 INJURIES OF THE BOXES OF THE FOREARM. Fig. 104. limited to the small arc through which the upper fragment can still supinate. The cause is therefore union with displacement at the periph- ery. The limitation may also be the result of union with axial displace- ment if the forearm is meanwhile pronated. If union takes place with the arm angularly inflexed and pronated, the interosseous ligament is stretched at the point of inflexion by slight rotation, as it is too short for the false position and for the wide excursion of the bones at the point of deformity during rotation, v. Volkmann showed that angular union of one bone of the forearm, either the radius or the ulna, may cause the same limitation of supination, in that during rotation the interosseous ligament cannot follow the excursion required at the angle. Treatment. — The knowledge of these displacements and the disturb- ances produced by them is very essential for the treatment. The ordinary transverse fracture without displaee- _ ment heals in three to four weeks by simply immobilizing. Whatever splint is used should extend above the elbow and below the wrist to prevent rotation. The fingers should remain free and be exercised actively and passively to prevent stiffness. It has been known for a long while that the approximation of the frag- ments of the forearm depends upon the position of the hand in rota- tion. Formerly the attempt was made to separate the bones of the forearm by coaptation pads applied beneath the splint upon the front and back of the forearm, but as they were apt to produce constriction and circulatory disturbances they were abandoned. The separation of the bones of the forearm is secured more easily by immobilizing the hand in supination or in semirotation, the so-called "intermediary" position. Marked displacement of the fragments, as in Fig. 161, may necessitate anaesthesia to effect apposition; strong traction is made upon the hand, the upper arm being held semiflexed, together with direct manipulation of the fragments. As mentioned, exact adaptation of the fragments is very important for the subsequent function of the arm. For severe fractures the a*- ray should be used if possible as control. Angular inflexion should be corrected and prevented by supinating the hand. If in the case of children, by reason of the shortness of the forearm, a strip splint cannot be applied, the entire arm may be immobilized extended with the hand supinated. As direct violence is the common cause of fractures of the forearm, compound fractures are not infrequent, as from machinery accidents, run-over accidents, etc. Perforating frac- Old fracture of both hones of the forearm with overriding. FRACTURE OF THE S1IAFT OF THE ULNA. 251 tures of the lower third of the arm also result from a fall upon the hand. There is nothing particular to add in regard to their treatment; the edges of the wound arc excised after appropriate cleansing and disinfection; if the projecting fragments are much soiled, a portion may be resected. The subsequent treatment of fractures of the forearm should aim to prevent stiffness of the fingers and hand by timely removal of the splint; further, the ringers should he exercised during immobilization. In three to four weeks union is usually sufficiently firm to permit of re- moval of the splint. Stiffness of the fingers and the wrist should then be overcome energetically by massage and active and passive motion. If malposition, especially inflexion at the point of fracture, produces much limitation of motion, improvement may be obtained by osteotomy. Synostoses or callus compromising the function are occasionally oper- able in view of the protection afforded by modern asepsis. Pseudarthrosis occasionally results from these fractures, even where the displacement is slight. In some instances the cause, whether an interposition of soft parts or lack of bone production, is not known. It has been observed also following fracture of one of the bones, and following compound fractures in which portions of the bone were removed on account of extensive destruction or infection ; in these latter cases the false joint may be so loose as to give the so-called "flail-hand," the lower part of the forearm swinging like a pendulum at every move- ment. The treatment of pseudarthrosis is often difficult. Of the various methods proposed to stimulate ossification, the author will mention only the insertion of ivory pegs and suture of the bone. As the first method is not always successful, it is advisable in the forearm, in which the bones, especially the ulna, are very accessible, to suture the fragments with iron or bronze wire. Suture of the ulna is not difficult, on account of its superficial position; in suturing the radius the nerves should be guarded. If the fragments can be drawn apart, they may be drilled and sutured. In other instances in which it is not desirable to freshen the fragments a figure-of-8 wire spiral may be wound around them. If operation is unsuccessful or refused by the patient, the hand can be made more useful by a sheath apparatus. Even in the case of flail- hand, wdiich is quite useless without an apparatus, by means of a simple sheath surrounding the lower part of the upper arm and the forearm to the hand, the hand is able to grasp and carry light objects. FRACTURE OF THE SHAFT OF THE ULNA. Etiology. — Isolated fracture of the shaft of the ulna is caused ex- ceptionally by indirect violence, a fall upon the hand, commonly by direct violence, a blow, or pressure; it occurs very often in the form of so-called "parry-fracture," from a blow upon the arm uplifted to protect the head. This blow has to strike the ulna alone and in a certain position. The bone is thus broken inward, the fragments being 252 INJURIES OF THE BONES OF THE FOREARM. driven into the interosseous space. Many authors question whether isolated fracture of the ulna can he produced by violent torsion, pro- nation, or supination. Symptoms. — In the absence of displacement the fracture is evidenced by the localized pain on pressure, easily obtained by reason of the superficial situation of the bone, and by the swelling and ecchymosis. Crepitus and false motion are elicited by moving the fragments on Fig. 165. Fig. 160. ■Gunshot-fracture of the ulna (Turkish-Grecian War). (Kiittner.) Fracture of the ulna with dislocation of the radius. each other, if displacement is more pronounced, the diagnosis is not difficult; the edges of the fragments may be felt through the skin. An example of isolated gunshot-fracture of the ulna is shown in Fig. 165, the ball lying in the soft parts of the lower end of the forearm. The ball entered on the radial side of the upper end of the forearm, struck and fractured the ulna transversely, and passed downward upon the interosseous ligament, marking its path by a leaden streak. FRACTURE OF THE SHAFT OF THE RADIUS. 253 Prognosis. — The prognosis of isolated fracture of the ulna is favorable, as the radius acts as a splint to hold the replaced fragments in position. The prognosis of shot-wounds or other compound fractures depends upon the course of the wound. Treatment. — A simple splint is sufficient; union usually occurs in three to four weeks. Operative reduction is seldom necessary, as the functional results are good in spite of persisting displacement. FRACTURE OF THE ULNA WITH DISLOCATION OF THE RADIUS. In the section on Dislocation of the Radius it was mentioned that fracture of the ulna is not infrequently accompanied by dislocation of the radius. The combination results either from direct violence applied on the outer side of the arm and breaking first the ulna, then causing the dislocation of the radius; or it may result indirectly from a fall upon the hand or from a combination of several forces. Under Injuries of the Elbow-joint the author discussed the symptoms, prog- nosis, and treatment of this injury, and noted that the ulna is almost always fractured in the upper third. The accompanying illustration (Fig. 166) shows the manner of displacement of the fragments. Helferich and Dorfler think that the fracture is situated in the upper third without exception. Oberst's experience does not verify this opinion, and the author has seen 2 cases in which the fracture was in the middle third. For details of the diagnosis and discussion of the difficulty of maintain- ing the reposition of the head of the radius the reader is referred to the section on Dislocation of the Radius. Diagnosis. — Fracture of the ulna is usually recognizable by the angular inflexion at the point of fracture and the depression of the skin. There is generally evident shortening of the forearm from displacement of the fragments. False motion and crepitus, more distinct during rotation, confirm the diagnosis. Treatment. — The fragments are reduced by direct pressure and the dislocation of the radius overcome by traction upon the forearm and pressure upon the head. The arm is immobilized in semiflexion or acute flexion with the hand in semirotation. At the end of the third or fourth week the splint is removed and massage and exercise begun. If the head of the radius shows a tendency to dislocate, it may be held in place by traction and pressure upon the head of the radius and the upper end of the shaft. This is most effective if the head is dislocated forward. The necessity of occasionally resecting the head has been discussed elsewhere. FRACTURE OF THE SHAFT OF THE RADIUS Fractures of the head and neck of the radius were discussed under Fractures of the Elbow. The frequent fracture of the lower epiphysis of the radius will be discussed in the section on the Wrist-joint. 254 INJURIES OF THE BONES OF THE FOREARM. Etiology. — Fracture of the shaft of the radius is caused by direct violence, as a blow, pressure, crushing; less frequently indirectly, by a fall upon the hand. The line of fracture is commonly transverse; it may be longitudinal or spiral when produced by forced pronation or supination. The displacement of the fragments is usually slight; it has a distinct form according as the fracture lies above or below the insertion of the pronator teres, as the effect of pronation and supination acts in various ways; in general the influence of the muscles upon the position of the fragments is not to be overestimated. The upper frag- ment of the radius is inclined to become supinated and be displaced backward; the lower fragment to become pronated and enter the inter- osseous space. The middle third is the common seat of fracture. Oberst notes the frequent coexistence of fracture of the styloid process of the ulna, which is also often reported with isolated fracture of the shaft of the ulna. Diagnosis. — The diagnosis is made from the swelling, localized tenderness on pressure, and crepitus with false motion; pronation and supination and the use of the hand are lost. If the displacement is slight in muscular subjects, accurate diagnosis may be difficult. Treatment. — The treatment is usually simple, good apposition and immobilization in a strip or plaster splint being sufficient. Union takes place in three to four weeks. The hand should also be immobilized supi- nated in the splint with the fingers free. If the fragments are markedly displaced, proper apposition is impossible in many cases even by traction on the hand and direct manipulation of the fragments; if care is taken, however, to fix the hand in supination, the limitation of rotation is usually slight. The measures advised for isolated fractures of the ulna and fractures of both bones of the forearm apply to angular union of the ulna. CHAPTER XV. • DISEASES OF THE BONES OF THE FOREARM. OSTEOMYELITIS OF THE BONES OF THE FOREARM. Osteomyelitis of the radius or ulna is rare. In 470 cases reported by Haaga from v. Brims' clinic the radius was affected in 5 per cent., the ulna in 3 per cent, of the cases. Symptoms. — In regard to the general symptoms, there is nothing characteristic to add to the well-known general features of osteomyelitis. The local inflammation and tenderness are limited to the diseased bone, Fig. 167. Fig. 168. Sequestrum in the ulna from osteomyelitis. (v. Bruns.) Osteomyelitis of the radius and ulna. the radius or ulna. After perforating through the periosteum the suppu- ration spreads rapidly in the numerous intermuscular spaces and soon leads to extensive swelling of the entire arm. If the process begins in the epiphyseal lines of the upper ends of the bones of the forearm, it is accompanied by purulent inflammation of the joint. The wrist-joint may also be attacked by the inflammation. Early and numerous incisions (255) 256 DISEASES OE THE BONES UE THE FOREARM. on the forearm, and finally drainage of the joint, will be required to insure free discharge of pus. The casting oft' of the sequestrum may he expected in from eight to ten weeks; its size may vary greatly. Occasionally, as shown in the .r-ray picture Fig. 167, small sequestra lie in several cavities communicating through narrow openings. The entire diaphysis, and more frequently that of the radius than of the ulna, may sequestrate. The .r-ray demonstrates beautifully the situa- tion of the cavities and sequestra. Treatment. — The incision for sequestrotomy of the radius should not be too long, in order to save the soft parts. The bone is best approached between the tendons of the supinator longus and extensor carpi radialis, a little below the middle of the forearm. The incision naturally varies Fig. 169. Periosteal spindle-cell sarcoma of the ulna. ( Trendelenburg. 1 according to the position of the fistula. The tendons of the abductor pollicis longus and extensor pollicis brevis crossing the outer side of the radius at its lower end must be avoided. Sequestrotomy is very simple on the ulna, as the bone lies throughout its length beneath the skin on the inner side of the forearm, so that no important structures can be injured by the incision. In the operation it is best to first divide the fistula and then gouge out a gutter-shaped opening along one edge of the bone, through which the sequestrum is removed. Months may be required for complete closure of the bony cavity. Limited mobility of the fingers and hand, or even severe con- tractures, may result from the extensive subfascial inflammation accom- panying osteomyelitis; likewise impairment of motion or ankylosis of the joint from suppuration in the elbow. Still, fairly good mobility may TUMORS OF BONES AND SOFT FARTS OF FORFARM. 257 generally be obtained by timely motion begun after subsidence of the chief symptoms of inflammation. The angers should never be included in the bandage, and especially not in extension. If contractures result from improper treatment, good results may be obtained by energetic mechanical treatment, warm baths, and massage. TUMORS OF THE BONES AND SOFT PARTS OF THE FOREARM. Sarcoma is the most frequent tumor of the bones of the forearm, and is either periosteal (Fig. L69) or myeloid (Fig. 170). The peri- Fig. 170. Myeloid sarcoma of the radius. (Trendelenburg.) Fig. 171. X-ray of Fig. 170. osteal form is usually a spindle-cell sarcoma, the myeloid a giant-cell sarcoma. Fig. 1(39 represents a periosteal sarcoma of the ulna in a Vol. Ill— 17 258 DISEASES OF THE BONES OF THE FOREARM. woman sixty years old; Fig. 170, a giant-cell sarcoma of the radius in a woman thirty-two years old, which had reached this enormous size in one and one-half years. The .r-ray picture (Fig. 171) of this tumor shows its very extensive growth in the radius while the ulna remained intact. Two years after the operation the patient has had no recurrence. Although an advanced sarcoma demands amputation or exarticulation, smaller tumors of the bone, especially giant-cell sarcomata, which are comparatively benign, may permit of resection of the bone with eventual shortening of the other sound bone. Chondroma and chondrosarcoma are seen less frequently in the forearm than in the shoulder; osteoma is also rare. In cases of multiple exostosis many exostoses have been seen in the ulna and in the radius, chiefly on the lower end near the epiphyseal line. The fascial sarcomata are usually spindle cell, rarely round cell. Myoma and mixed tumors are rarities and only require mention. Gangrene of the lower part of the forearm is discussed with the wrist- joint. Angiomata occur both in the skin and the underlying soft parts. (See also Diseases of the Vessels of the Soft Parts of the Forearm.) CHAPTER XVI. OPERATIONS ON THE ELBOW AND FOREARM. LIGATION OF THE RADIAL AND ULNAR ARTERIES. Ligation of the Radial Artery. — The radial artery is not often ligated in the upper part of the forearm; incision at this point is made at the junction of the middle and upper thirds of the arm at the inner edge of the supinator longus and pronator teres, and is continued down between the flexor carpi radialis and supinator longus to the artery beneath. On the radial side of the artery lies the superficial or sensory branch of the radial nerve. It is more often necessary to ligate the artery above the wrist, where the pulse is felt, and where the vessel is frequently cut by trauma or suicidal attempts. The artery is found between the tendons of the supinator longus and flexor carpi radialis; it lies superficially imme- diately beneath the skin and thin fascia between two small veins. Ligation of the Ulnar Artery. — ligation of the ulnar above the middle of the forearm is also seldom necessary; if so, it is much easier to ligate the cubital artery; the incision is made on the inner side of the arm close to the radial border of the flexor carpi ulnaris, and is continued into the space between the flexor carpi ulnaris and flexor sublimis; these muscles are pushed aside and the artery is seen at the bottom of the wound lying upon the flexor profundus. The ulnar nerve lies to the ulnar side of the artery. For ligation of the ulnar artery above the wrist, the incision is made to the outer or radial side of the flexor carpi ulnaris, whose tendon is easily felt by flexing the hand; the incision therefore lies in the pro- longation of the outer border of the pisiform bone. After dividing the skin and thick fascia of the forearm the edge of the tendon of the flexor carpi ulnaris is exposed. One must be careful not to make a miscut beneath this tendon. The artery with two small veins lies beneath the deep fascia of the forearm. The ulnar nerve lies to the ulnar side. AMPUTATION OF THE FOREARM. Severe injuries of the hand or lower part of the forearm are not infrequent indications for amputation. If the lesion extends up almost to the elbow, one must choose in some instances between amputation of the forearm below or at the elbow. As already mentioned, a short (259) 260 OPERATIONS OX THE ELBOW AXD FOREARM. stump of forearm is very important for the use of the arm and the application of a prothesis, so that one should always choose in favor of amputation below the elbow in such cases if possible. The skin may be divided by a circular incision, and after a longitudinal incision on the radial and ulnar sides two skin-flaps of equal lengths — cuffs — may be dissected back. The muscles are divided by a circular incision. The catling is then inserted in the interosseous space on the extensor side of the ulna and brought out on the extensor side of the radius; in the same manner the soft parts of the interosseus space are divided on the flexor side. The two bones are sawed through together. The ulnar, radial, and muscular branches, and in the upper and middle third the interosseous artery, are to be ligated before removing the tourniquet. The radial artery in the upper third lies at some depth between the supinator longus and flexor carpi radialis upon the pronator Radial artery. Pronator teres. Radial nerve. Fig. 172. Flexor carpi Median Palmaris radialis. nerve, longus. Flexor sublimis. Ulnar artery. Ulnar nerve. longus. Extensor carpi radialis. Supinator b re vis. Extensor digituntm. . np,nato> ~k-^tj:l^m<^A^^^^m^\ Flexor pro- fundus. Posterior inter- Extensor Extensor Extensor carpi osseous nerve, minimi pollicis ulnaris. digiti. longus. Cn (SS-s eetion of forearm at junction of upper and middle third, i?, radius; V, ulna. teres. The superficial branch of the radial nerve lies to the radial side of the artery. The ulnar artery in the upper third lies between the flexor sublimis and profundus. One-quarter to one-half inch to the ulnar side in the same interspace lies the ulnar nerve; the median nerve lies at the same distance on the radial side. The relations in the ampu- tation surface are shown in Fig. 172. If the amputation is higher up, the ulnar artery lies nearer the median nerve; farther down it approaches the ulnar nerve. In the middle and lower thirds of the forearm the arteries and nerves are easily located (see ligation of arteries); here the ulnar nerve lies to the ulnar side of the artery as far as the wrist; the radial nerve to the radial side of the artery, diverging from it a little below the junction of the middle and lower thirds of the arm to proceed backward beneath the tendon of the supinator longus. OPERA TIONS <>X THE NERVES OF THE FOREARM. 261 In the upper third the median nerve lies to the radial side of the ulnar artery, beneath the pronator teres and flexor sublimis. In the middle of the forearm it lies between the superficial and deep flexors, becomes more superficial toward the hand, and above the wrist lies to the radial side of the palmaris longus between the tendons of the flexor sublimis. It is advisable in amputating to divide the nerve one-half to an inch higher than the muscles and vessels, so that the ends will not lie in the plane of the amputated surface and give rise to neuromata on the ends of the stumps. In most of the amputations for injuries, the stumps of the bones will be covered in by a flap incision instead of a circular incision. According to the extent of the injury, it may be necessary to form the flap on the radial, ulnar, extensor, or flexor surface. If the operation is to be bloodless, instead of the Esmarch bandage one should use preferably a broad rubber band, either of the style of Xicaise's or Martin's. The sharp constriction of the rubber band causes lesions of the nerves resulting in paralysis of the hand and forearm, which takes months to recover. If on account of complicated operations on the forearm or elbow it is necessary to constrict the arm more than an hour, the bandage should be shifted from one point to another so that the constriction is not applied too long in one spot. OPERATIONS ON THE NERVES OF THE FOREARM. Suture of the nerves may be required for injuries produced by puncture, stab, incised, or gunshot- wounds; the position of the nerves is given in the preceding section. The median nerve in the upper third of the forearm is reached through an incision between the supinator longus and flexor carpi radialis. The radial artery is exposed; at its ulnar side the pronator teres is divided and the nerve found. Farther down the nerve passes under the flexor sublimis. In the middle of the forearm the incision is made between the flexor carpi radialis and palmaris longus. The flexor sublimis is drawn aside; beneath it lies the nerve. Above the wrist the nerve lies to the radial side of the palmaris longus between the tendons of the flexor sublimis. The ulnar nerve, lying to the ulnar side of the ulnar artery, is easily found through the incision given for the artery. In like manner the superficial sensory branch of the radial nerve, which accompanies the radial artery on the radial side to the lower third of the arm, thence passing to the dorsum beneath the supinator longus. The deep branch of the radial nerve lies hidden beneath the extensor carpi radialis longus. The incision is made below the head of the radius between the extensor carpi radialis longus and extensor communis. The nerve is exposed on retracting the muscles. It emerges from the supinator brevis, which is recognized by its oblique fibres. Farther down it divides into its mus- cular branches and the posterior interosseus. 262 OPERATIONS ON THE ELBOW AND FOREARM. In operations on the forearm for ligation, suture of nerve or tendons, operations on the bones, etc., the distribution of the arteries and nerves must be considered. The ulna is approached without difficulty on its inner surface: the radius is best exposed through an incision to the outer (radial) side of the radial artery. Through this incision the interosseous ligament is accessible after separating the muscles from the radius; in the lower half of the arm the interosseous ligament is approached at the side of the median nerve. CHAPTER XVII. ACCIDENT AND JUDGMENT. A large proportion of the accidents requiring medical testimony are those resulting from the manual control of machinery in the ex- tensive mechanical industries of the present time. As the loss of the hand, the apparatus and instrument of prehension and touch, is conclusive in injuries involving the loss of part of the upper extremity, the level of amputation is of slight importance in estimating the loss in earning-efficiency. Further, whether the amputation is at the elbow or in the upper or lower third of the forearm is of little moment for the working ability of the individual. The degree of impairment in earning-efficiency is estimated, to have some standard of calculation, at 100 per cent, in the case of exarticulation or amputation of both fore- arms, and in the loss of the right forearm, between 70 and 80 per cent. Defects in or impairment of the left arm are usually estimated about 10 per cent, below the same in the right arm; so the loss of the left fore- arm=60 to 70 per cent. Loss of both hands or forearms is really not represented adequately by an earning-deficiency (or disability) of 100 per cent., as the personal attendance required by the patient should be taken into account; recent estimates place the proper percentage at 125 to 130 per cent, for the case in question, assuming a loss in earning- efficiency of more than 100 per cent. In injuries of the nerves of the forearm resulting in paralyses of the hand the degree of impairment of the hand is naturally conclusive. In paralysis of the radial the hand is practically useless without a sheath apparatus. If the right is affected, the loss in earning-efficiency amounts to 60 to 70 per cent., if the left 50 to 60 per cent.; paralysis of the ulnar or median alone is reckoned at 60 to 70 per cent, on the right side, on the left, 50 to 60 per cent. ; paralysis of the radial, ulnar, and median combined, on the right, 70 to SO per cent., on the left, 60 to 70 per cent. In radial paralysis the loss in earning-efficiency can be compensated 20 to 30 per cent, by the sheath apparatus. All results of compound fractures and inflammations of the forearm are estimated as equal to the loss of an arm, if the fingers and hand are entirely stiffened. The loss in earning-efficiency in ankylosis of the elbow at a right angle is placed at 35 to 40 per cent.; at an obtuse angle or extended, 50 to 60 per cent. In actively-loose joint of the elbow, loss on the right side 50 to 60 per cent., on the left, 40 to 50 per cent.; in passively-loose joint, as the hand is entirely useless, in the right, 60 to 75 per cent., in the left, 60 to 70 per cent.; the loss is decreased 20 to 35 per cent, by sheath apparatus. ( 263 ) 264 ACCIDENT AND JUDGMENT. It is advisable to allow co-operative associations a slight margin in the estimate; in other words, to state that the loss in earning-efficiency resulting from the accident under consideration is regarded as about 50 to (>0 per cent. The co-operative association selects, according to the circumstances of the case, the higher or lower interest; to be sure, there are considerations influencing the economical aspect of the question which the physician is often unable to estimate. Some of the co-operative associations absolutely reject any statement of the earning-deficiency in percentages, and desire the physician to state definitely as to how severe the injury is; whether there is complete loss of earning-efficiency or whether it is very severe, or severe, moderate, slight, or very slight. These are the grades which they use as a basis of calculation. The method certainly has its justifications. If motion is limited at the elbow, after fractures, to 50 degrees, the result would be perhaps an earning-deficiency of 20 per cent. The essential element in the disturbance is the impairment of rotation of the hand; if it is checked entirely, the earning-deficiency is always increased from 15 to 20 per cent, for the right hand, 10 to 15 per cent, for the left. If stiffness of the individual fingers results from severe laceration of the muscles of the forearm, the loss in earning-efficiency will depend upon the extent to which the motion of the fingers is limited. Fractures of the forearm or of the elbow in elderly individuals of the labor- ing class are almost always followed by more or less stiffness, muscular weakness, and oedema in the hand — the latter being apt to be combined with rheumatic pains — and limit the earning-ability; these sequela? even follow a recovery uneventful from the outset, and in the common fractures of the forearm the loss incurred varies from 20 to 40 per cent. In younger subjects there is generally no permanent loss, but damages are collected on account of the pain, the existence of which often cannot be disproved. All statements of the time of recovery of fractures, given in the course of transactions, take into account only the consolidation of the bone. That does not mean that the fractured limb is able to be used, for as a rule the arm is not fitted for work until two to three weeks after con- solidation in the case of fractures unaccompanied by severe lesions of the soft parts, and not until four or five weeks later where the soft parts were badly contused and lacerated. During this time massage, warm arm baths, electricity, and exercise with apparatus are understood to have been employed. At the end of this period, in which the patient is still to be regarded as unfit for work, begins the period of renewed activity and partial earning-efficiency, in which, to formulate the estimate, an earning- deficiency of about 50 per cent, still persists for three weeks longer in the case of severe fractures, and then the deficiency decreases to about 20 to 30 per cent. At the end of six months the examination determines whether the improvement has continued or whether the remaining impairment will be permanent. MALFORMATIONS, INJURIES, AND DISEASES OF THE WRIST AND HAND. By Prop. Dr. P. L. KKrKDIUCH. Preliminary Remarks on the Anatomy and Technic of Examina- tion. — In the slight compass of the hand there are twenty-seven small bones, compactly arranged and adjustable and movable by the action of forty muscles. In a structure capable of such numerous movements it can be understood how even slight disturbances may entail functional loss. The functional power of the hand of the laboring-man often deter- mines his entire earning ability. An accurate knowledge of the normal function is therefore indispensable for the recognition of pathological changes. On the fingers as well as on the hand are distinguished four sides or surfaces: flexor or volar, extensor or dorsal, ulnar and radial. Surgeons speak of flexion (volar flexion), extension (dorsal flexion); in deviation of the hand toward the radial or ulnar side, abduction (radial inflexion), adduction (ulnar inflexion). The skin of the fingers on the flexor side is well supplied with tactile nerve-endings and lymphatics, contains more fat than that of the dorsum, is especially delicate on the ulnar and radial sides, and is therefore easily perforated here by inflammatory products from within. On the flexor surface of each finger are three deep folds, on the thumb two, corresponding to the joints. The proximal folds do not lie over the metacarpophalangeal joints, but y 7 ^ to yw mcri distally. They indicate the line of incision for exarticulation of the fingers. The next row corresponds to the first interphalangeal joints. The third folds lie j inch proximal to the second interphalangeal joint. The skin on the flexor surface of the fingers is normally only slightly movable. Therefore inflammation rapidly causes a feeling of marked tension. Strong bands of connective tissue unite the skin and under- lying tendon-sheaths at the folds of the fingers, so that in inflammations of the skin the fold is often deepened; in exudations within the tendon- sheaths the folds are levelled off and effaced. The folds at the base of the fingers are held by peripheral radiations of the palmar aponeurosis, the distal fibres of which extend to the base of the second phalanx, sometimes even to the terminal phalanx. The tendon-sheaths run immediately beneath the subcutaneous layer of fat, beginning usually at the head of the metacarpus and ending at the base of the third phalanx. Slight variations occur. Those of the thumb and fifth finger are somewhat longer, extending almost to the wrist, ( 265 ) 266 MALFORMATIONS AND DISEASES OF WRIST AND HAND. where they communicate — or only that of the thumb — with the common tendon-sheath. The tendon-sheaths are attached to the anterior surface of the capsule at all the finger-joints, and on the phalanges to the under- lying bone. They each enclose a flexor sublimits and profundus tendon; but on the thumb only the tendon of the flexor pollicis longus. They are everywhere strengthened by fine transverse fibrous bands which are extremely delicate at the joint to allow free motion. The nerves and vessels run at the sides of the tendon-sheaths. The excess of skin on the flexor surface and the greater mobility of the same on the extensor surface of the fingers are explained by the predominance of the flexor action. Over the joints on the dorsum the average thickness is only 2 mm. so that slight puncture-wounds pene- trate easily; hence the greater frequency of inflammatory affections of the joint following injuries on the dorsum. The vulnerability of the nail-fold favors the production of cutaneous inflammations (paronychia) ; the abundance of sweat-glands in the skin on the dorsum the production of folliculitis. The matrix extends back about 2 mm. beneath the skin fold, as is easily felt by pressing upon the projecting edge of the nail. This is to be taken into account in incising to extract the nail. The extensor tendons lie immediately beneath the thin skin without any particular sheath; their flatness is increased over the joints, so that in this situation they are quite broad. The end of the middle tendon is inserted in the base of the second phalanx, the two lateral tendons in the third phalanx. The base of each phalanx can be felt in flexion through the tendons; in order to incise upon the bony margin of the base to exarticulate, the transverse incision is made 2 to 7 mm. distal to the flexor prominence of the joint. The dorsal transverse folds over the joint have no value as landmarks. On account of the thinness, looseness, and ful- ness of the skin on the dorsum over the joints, and the thinness and width of the dorsal part of the capsule, the skin is distended like a sac by inflammatory exudates in the joints. All exudates (inflammatory, rheumatic, hemorrhagic) force the fingers into a position of slight flexion at the diseased joint, the position giving the greatest room in the joint, and on this account the most comfortable position for prolonged im- mobilization of the finger. The metacarpophalangeal joint is capable, besides flexion and ex- tension, of limited abduction and adduction if the fingers are extended. Normally these lateral movements are not possible in the interphalangeal joint; still it is characteristic of children, particularly of the female sex, and women, that frequently the joint-surfaces can be displaced passively upon each other backward, forward, or laterally. The same applies to individuals who have not recovered from the effects of lesions loosen- ing the ligaments. The excursion of motion in the finger-joints varies in the individual. Normally there is moderate active hyperextension in the metacarpo- phalangeal joints and flexion to a right angle. Passively hyperextension can be increased more than flexion. The interphalangeal joints usually MALFORMATIONS AND DISEASES OF WRIST AND HAND. 267 permit of extension only to a straight line. Pianists and people with unusual suppleness can sometimes increase the extension considerably. Flexion generally reaches an acute angle of about (50 degrees. In the second interphalangeal joint a righl angle can be readied actively only with some effort. In determining pathological changes the affected hand should he compared with the sound one if accessible. This applies as well to measuring the phalanges and the joints. Fig. 173. Tendon-sheaths of the flexors. Showing relation of the sheaths to the deep palmar arch and the lines of the palm. The latter are indicated by the black lines. (His and Spalteholz.) The position held by the thumb is unique. The free mobility of the thumb is the most important factor in the earning-efficiency of the human hand. To save everything that can be saved should be the surgeon's first principle in the surgical treatment of injuries of the thumb. For this reason all functional disturbances affecting the thumb are more important than those of the other fingers. 268 MALFORMATIONS AND DISEASES OF WRIST AND HAND. The skin of the palm, often callous and thickened, is firmly adherent to the underlying palmar aponeurosis, and so only slightly movable. Hair and sebaceous glands are absent. Hence genuine furuncle and atheroma do not occur. It is only in diabetes that one occasionally meets with a painful circumscribed inflammatory infiltration of the palm similar to furuncle. The two transverse folds in the palm form a line which marks approximately the position of the metacarpophalangeal joints and the beginning of the tendon-sheaths of the fingers. (See Fig. 173.) The palmar aponeurosis is most strongly developed in the centre. Palpation of the base of the hand on the dorsum is aided by many anatomical points. Running the first finger upward along the radial side of the first metacarpal one feels a slight projection at the base to which the tendon of the abductor pollicis longus is attached. In the same way on the ulnar side of the fifth metacarpal one comes upon a small prominence at the base, and by ulnar adduction and extension of the hand the extensor carpi ulnaris attached to it can be felt. A slightly curved line, convex downward, joining these two bony points lies directly over the line of the carpometacarpal joint. Running the finger downward along the shaft of the radius on its outer side a slight bowing, convex toward the dorsum, is felt at the lower third, and beyond, the club-shaped end of the bone. Passing inward from the styloid process of the radius the entire dorsal articular border of the radius can be felt— especially if the hand is slightly flexed — and the line of the radiocarpal joint (scaphoid, semilunar, and cuneiform) so important for the movements of the wrist. This joint is best examined on the dorsum. The triangular cartilage is the immediate continuation of the articular cartilage of the radius, and forms the boundary between the radio-ulnar joint and the wrist; exceptionally there is a communi- cation, as demonstrated by M. Schiiler by injection. The disk can be felt only in very thin hands. Under the same conditions the dorsal branches of the radial and ulnar nerves can be moved about beneath the skin. On the flexor surface of the wrist the tuberosity of the scaphoid, slightly to the inner side of and below the styloid process, and the tra- pezium on the radial side, and the process of the unciform and pisiform on the ulnar side, represent the pillars of the vaulted arch of the carpus. The bones are frequently contused in falling upon the outstretched hand, fragments may be torn off, or the bones may be crushed and remain painful for a long time. The bony structure of the wrist is divisible with reference to motion into three parts. Pronation and supination take place in the radio- ulnar joint, which is separated from the wrist by the cartilaginous disk. Flexion and extension take place between the cartilaginous surfaces of the radius and cartilaginous disk and the condyloid head formed by the scaphoid, lunar, and cuneiform — the radiocarpal joint (first joint). The second joint is composed of the distal cotyloid surfaces of these bones and the combined condyloid surface of the os magnum and MALFORMATIONS AND DISEASES OF WRIST AND HAND. 269 unciform. The connection between the distal carpal row and the metacarpals is very firm, having essentially no joint-action; only the first metacarpal forms a more freely movable saddle joint with the os magnum. \V. Braune and (). Fischer by careful investigations have determined the range of motion in the wrist as a whole and in the several sections. It appears that the position of the hand has a decided influence upon the range of motion. Taking the middle position of the hand as a starting-point, whereby ulnar and radial inflexion, flexion and extension, are about equal, it follows that the combined movements of the hand take place simultaneously in both joints. Ulnar inflexion is possible to 20 degrees, 55 per cent, of which occurs in the radio- carpal, 45 per cent, in the midearpal joint. Flexion is possible to 87 degrees, of which 70 per cent, is in the first joint, 30 per cent, in the midearpal (second joint). Radial inflexion (27 degrees) and dorsal flexion (86 degrees) take place chiefly in the midearpal joint. The information given by Braune and Fischer is verified by R. Fick in a very careful study with the ar-ray of the movements of the wrist. The long flexor and extensor muscles of the hand control the position of the wrist in as far as the position of the finger-joints favors or limits the range of motion in the wrist; inversely, the position of the wrist is significant for the contraction of the finger muscles. The elements of the wrist are bound firmly together in their proper position by strong ligaments. The dense outer portion of the anterior ligament running from the styloid process and adjacent articular surface of the carpus to the scaphoid, lunar, and cuneiform, holds the carpal head formed by the latter against the radius. Its power of resistance is greater than that of the radius, so that in falling upon the extended hand the bone breaks more easily than the ligament is torn. The posterior ligament corresponding to it is less firm. The other flexor ligaments are also well developed. The ligament running from the scaphoid and trapezium to the unciform and pisiform bones also gives stability; it covers the flexor tendons and median nerve. The inter- communication of the various joints is favorable for the dissemination of inflammatory processes in the wrist. As mentioned, the radio-ulnar articulation is closed off from the carpus by the cartilaginous disk. Inflammation rarely spreads from it to the carpus. The radiocarpal joint is separated from the midearpal. The latter connects with the carpometacarpal joint between the os magnum and trapezoid and between the trapezium and trapezoid. The joint between the cuneiform and pisiform not infrequently connects with the carpometacarpal joint. Retention of secretion is particularly liable to occur in the midearpal joint. From the above it can be understood that inflammation in the carpometacarpal joint spreads easily to the midearpal. In extra- vasation the synovial pockets bulge perceptibly at both sides of the extensors and give fluctuation. The tendon-sheaths sometimes com- municate with the joint at this point, and inflammation may spread in either direction. The best points for puncture and injection of the joints are below the styloid process of the radius and ulna. CHAPTER XVIII. MALFORMATIONS OF THE HAND EXCEPTING THE CONGENITAL CONTRACTURES. Anomalies of development are met with in the hand as in the foot — - namely, abnormalities as to size or number, either in the direction of hypertrophy or deficiency, and as to position. Congenital hypertrophy (Ubermass, Riesenwuchs) is more frequently limited to an extremity than to an entire body-half, and usually to the peripheral parts of the hand or fingers (macrocheiria and macrodactylia). The hypertrophy may involve all the tissues simultaneously, or, what is more frequent, single "systems," especially the adipose tissue (congenital "soft elephantiasis of Virchow"). It may involve the entire hand or preferably merely the palm or single portions of it. Simultaneous hyperplasia of the nerves and vessels (teleangiectasis and cavernous changes in the veins) have been repeatedly seen and described. In a boy twelve years old the author saw a simultaneous extensive hyperplasia of the sweat-glands forming small tumors. Whereas simple hypertrophy usually keeps pace with the growth of the rest of the body, the forms complicated by con- spicuous changes in the vessels often develop rapidly to enormous size, like tumors; the former harmless variety is properly termed true hyper- trophy, the latter false hypertrophy. (See also the corresponding description in the section Malformations of the Foot.) This distinction is not unimportant in reference to the prognosis. Surgical interference is indicated for hypertrophy only when the use of the limb is compromised. Wedge-shaped excisions usually have only a temporary effect. The same applies even more to changes producing compression. How far ligation of the main arteries can be of service has never been subjected, to the author's knowledge, to careful test. In hypertrophy inhibiting the function of single fingers, the member will occasionally be removed. The entire hand will be amputated only in cases of general deformity with rapid upward advance of the hyper- trophy. Such cases are rare; even in this manner Fischer could not check the process. In false hypertrophy more radical measures are required; careful removal of all tumor-like tissue is then demanded; finally, amputation if the bone is involved. Of more practical importance are the conditions of "excess" (Uber- zahl), adhesions, and position-anomalies of the fingers (polydactylia, syndactylia, and deviations'). In the entire series of vertebrates the extremities develop from the lateral ventral fold formed from the primal vertebral ridge, the Wolffian ridge. In the human species a longitudinal thickening is found, appear- (270) MALFORMATIONS OF THE HAM). 271 ing at the end of the third week, which corresponds in the upper extremity to the last two cervical ;nie regarded not as a pathological fusion, hut rather as the result of arrested development. Fig. 183. Fig. L84. -V-ray picture of Fig. 182. Ectrodactylia, symphalangia, brachydactylia. A"-ray picture of Fig. 181. Microdactylia, symphalangia. The process of separation of the fingers normally completed at the end of the second or beginning of the third month is incomplete on account of failure of the skin to retract. According to the level at which this takes place are observed various degrees of syndactylia, namely, cuta- neous union involving one or two phalanges or the entire finger. Such web-formations of skin are usually broader and more yielding the fewer the fingers involved. The bridges of skin are shortest when all the fingers are involved. On surgico-technical grounds one may classify syndactylia cutanea, fibrosa, and ossea; in the latter the nails are usually fused. As the fusion of the skin is generally closest at the terminal pha- langes, a variety is seen in which the syndactylic union is limited to 276 MALFORMATIONS OF THE HAND. the ends of the fingers, the more proximal parts being free; or the union may be bony at the ends and otherwise cutaneous. Complete bony union resembles defect of a finger. It is more frequently seen in the toes. It is impossible to discuss the manifold modifications here; mention of the most important will enable the surgeon to make the proper diagnosis in most of the cases. Operation is frequently necessary purely from an aesthetic standpoint, in syndactylia always from a functional standpoint. The parents and relatives are inclined to regard the malformation as unsightly, and at an early date to urge that the " paw-like " member be made nor- Fig. 186. Syndactylia ossea (third phalanx) with eetrodactylia of the third and fourth fin- gers, brachydactylia of the thumb, index and fifth fingers and rudimentary nails. A'-ray of case after operation, finger improved. Fig. 185 two and a half years Function of thumb and fifth mal. In polydactylia ligation even of pendulous digits is no longer performed; they are either cut off clean with the scissors, or, where the supernumerary fingers or phalanges articulate, they are excised through an oval incision. One or two small arteries of unusual size are some- times met with. If possible, the incision should not be on the palmar surface. If the forking extends into the shaft of the bone, the branch should be resected at its base. Where both branches are rudimentary the removal of 'one or the other will depend upon which branch gives the better prospect of usefulness and in the case of the thumb considers the power of adduction. For cases of divergent branching from the proximal MALFORMATIONS OF THE HAND. 277 base, for example, at the fifth metacarpal, in reduplication of the little finger, if there is a tendency to lateral deviation of one branch after removal of the other, Bilhaut's method, as used and recommended by Kummel, may be employed: both branches are freshened on the adjacent surfaces by means of a Y-shaped or Y-shaped incision, the limbs of which pass through the middle of both nails; the branches are apposed after removing the nails, and the matrices are sutured together. The results of surgical treatment of syndactylia are not very satis- factory. The number of methods extant, from the so-called method of Celsus (division of the skin-bridges to the commissure) to the modern plastic Hap methods testify as to the difficulty of treatment. In all the instances in which primary union was not obtained down to the com- missure during childhood a tendency is seen to secondary adhesion of the web-like bridges of skin. All the methods of tying, inserting threads or lead wire with or without puncture at the base, etc., are historical. Retraction of the commissure by means of elastic bands after division of the bridges, as performed by Lister, is no longer applicable. The idea of covering in the commissure at the outset was first carried into effect by Zeller: a dorsal skin-flap the length of the first phalanx, with its base at the commissure and its tip at the level of the first inter- phalangeal joint, is sutured to the flexor surface. On account of the danger of necrosis of the tip Pitha could not endorse the method. Velpeau sutured the angle of the commissure directly together. The method of Didot and Nelaton is much used : for example, where the third and fourth fingers are adherent, a wide dorsal flap, w T ith its base on the third, is freed from the fourth and used to cover in the ulnar side of the third; a corresponding volar flap from the third covers the radial side of the fourth. The commissure is closed by suturing the proximal edges of the two flaps. Where the bridge was very small, Dieffenbach turned down a flap from the dorsum into the commissure; v. Langenbeck covered in one of the fingers by a dorsal and a volar flap at the commissure, leaving the other finger uncovered. The width of the bridge usually determines the result of such plastic operations. The author always seeks to cover in the commissure accurately, making the flaps sufficiently loose to prevent necrosis. The covering in of the denuded areas appears to the author to be of secondary importance. This he has accomplished often by direct suture of the edges, best with silver wire; also by the Didot-Nelaton lateral flap method where the material was sufficient; also by Thiersch grafts. Even primary suture or grafting is not infrequently followed, however, by contractures and sensitive cicatrices. The ideal method is the application of pedunculated skin-flaps and the avoidance of cicatrices on the volar surface. In conclusion should be mentioned the results of "ray-defects" of the upper extremity, congenital anomalies in arrangement. By ray- defects are understood anomalies depending upon the absence of larger portions of a "ray," namely, of one of the morphological longitudinal divisions of the extremity. If the radius is partially or entirely absent, the hand is displaced in a position of radial abduction from the long 278 MALFORMATIONS OF THE HAND. axis, usually almost to a right angle. The radial border of the hand is displaced proximally, the skin of the latter reaching almost to the middle of the lower arm, the soft parts being defective. (Fig. 187.) The defect is almost always accompanied by defects of the thumb and of the thenar eminence. Ray-defects of the ulna are more rare, and the anomalies are all correspondingly in the opposite direction. The inadequacy of surgical measures liberates the author from further dis- cussion of these and similar, rarer deformities. Fig. 187 Radial rav-defect, in club-hand. Genuine congenital club-hand without defects gives better promise of treatment. It is characterized by a flexion contracture-position (talipomanus flexa) with simultaneous supination of the normally devel- oped hand in ulnar adduction, less frequently by a position of extension and pronation. The flexion of the fingers may be so great as to cause dorsal displacement of the phalanges, especially in the metacarpo- phalangeal joints (author's observation). Accompanying defects of single carpal bones have also been seen. The treatment of genuine club-hand is the same as that of club-foot: correction, immobilization, exercises, massage. (For congenital contractures, see section on Contractures, page 35G.) CHAPTER XIX. INJURIES OF THE WRIST AND HAND. CONTUSIONS AND SPRAINS OF THE WRIST. All bloodless injuries of the wrist not included under fractures and dislocations are classified as sprains. Countless fractures of the lower end of the radius have been diagnosticated as sprains not only before Colles' accurate clinical definition, but even at the present time. The diagnosis of sprain is admissible only after careful exclusion of severer injuries. Under this heading are still included a number of lesions which would be better defined by the anatomical details: stretching and laceration of the larger ligaments or of the synovial membranes of the individual bones with secondary extravasation in sections of or in the entire joint; laceration and avulsion of the tendons; comminution and fissures of the cartilage, lacking the signs of fracture, but still able to cause serious lasting disturbances. Whereas contusions are generally caused by direct violence, sprains may result from forced rotary movements, pronation and supination, flexion, extension, and radial and ulnar adduction. The mechanism may vary as greatly as the movements of the hand at the wrist. Frequently contusion and sprain are combined. The transverse ligament is usually torn slightly by the extension of the hand. Pain is elicited by pressure at the attachments on the pisiform, trapezium, and scaphoid. At the same time the flexor tendons and sheaths are sprained, as indicated by the pain on flexing the fingers and by the effusion in the tendon-sheaths. The synovial sacs on the volar side of the joints may be stretched, the dorsal edges of the cartilages of the wrist bones may be bruised by the pressure, and the injury start- ing on the volar side may be evidenced simultaneously by points of tenderness on the dorsum. Although not belonging here in the strict anatomical sense, a slight chipping off of the cartilage may occur and exist for some time under the diagnosis of sprain or contusion, and influence the later course of the contusion. Dislocation and avulsion of the tendons will be considered separately. In like manner contusion or sprain on the dorsum may be due to transmission of the force causing the injury on the flexor side; chipping off of the bone or cartilage of the carpus or metacarpus is not infrequent. By forced radial adduction the capsule of the wrist may be torn on the ulnar side, by forced ulnar adduction on the radial side. In the first instance the sheath of the extensor carpi ulnaris, in the second those of the extensor pollicis brevis and abductor pollicis longus, or the muscles themselves, may be torn. In the one case there may be slight ( 279 ) 280 INJURIES OF THE WRIST AND HAND. tear-fractures of the styloid process of the ulna, in the other of the same process of the radius. A complication of sprain by supination, important and yet easily overlooked, is the tearing of the capsule of the radio-ulnar joint, with or without injury — displacement — of the articular disk; the result may be protracted impairment of supination and pronation, and incomplete recovery. Forced pronation may tear the extensor carpi radialis longus. The same muscle is found frequently involved in flexion-sprain and contusion of the dorsum, the first evidence of which is a distinct point of tenderness on pressure at its attachment on the second metacarpal. In like manner in sprain by extension with direct injury of the flexor carpi radialis, the same tenderness on pressure is found at the attach- ment of the muscle on the base of the same bone. Extravasation in the wrist-joint is frequently found accompanying the above injuries, and is recognizable by the fact that it pushes up the dorsal tendons, causes bulging, and gives fluctuation of the capsule at both sides of the tendons. Diagnosis — The diagnosis depends upon careful palpation and the exclusion of severer injuries. The points of tenderness obtained by testing the function and by pressure are usually accurate guides. The changes are often quickly recognized by comparing with the sound hand. A suspected fissure or slight chipping off of bone may be only recognizable by means of the .r-ray. Treatment. — Slight sprains without palpable changes merely require protection, subsequently massage and judicious use. All severe sprains require immobilization. The joint as well as the sprained or partially torn ligaments require fixation; the pain diminishes rapidly. Union of the ligaments and complete restoration of function are best assured by a position opposite to the direction of the violence, namely, in sprains by extension in the flexed position. Without exception the author uses pasteboard-strip splints or thin plaster-strip splints moulded to the arm, the technic of applying which will be de- scribed under Fractures of the Radius. By this means all secondary loosening of the ligaments, which is less to be feared in the wrist than, in the ankle, is best prevented, and the exudation in the tendon-sheaths has a correspondingly larger space so that the return of function is quicker and less painful. Aspiration of the joint will seldom be necessary. Old sprains and contusions and their sequeke — ankylosis of the tendons and sensitiveness in movements of the joint — require passive movements, exercise and massage, baths, hot compresses or the hot-air apparatus. Occasionally in treating "old" sprains one finds a lesion of greater im- portance than is conveyed in the concept " sprain." In such instances the manipulation leads to better recognition and indicates the use of knife or chisel. ISOLATED INJURIES OF THE TENDONS. Dislocation of the Tendons. — A traumatic displacement . of the tendons of the hand and fingers comparable in importance to displace- ISOLATED INJURIES OF THE TENDONS. 281 ment of the tendons of the peronei in the foot is unknown. Displace- ments of the tendons, however, frequently accompany fracture and dislocation of the hones, and their reposition goes hand in hand with the treatment of these injuries. In a number of instances of dislocation of the thumb there has been lateral displacement — and hooking — of the tendon of the flexor longus pollicis. Helferich especially has called attention to this hindrance to reposition. The tendon in question slips over the neck of the first metacarpal, which latter in forced lateral displacement of the joint- surface holds the tendon back like a hook. The displacement can often be overcome by strong ulnar inflexion of the first phalanx of the thumb. In old contractures the tendons are often found displaced later- ally. Further, one should remember the ulnar displacement of the ex- tensors in arthritis deformans of the metacarpophalangeal joints. In cases of habitual dislocation, as in dislocation of the first metacarpal on its carpal or of the first phalanx on its metacarpal, a lateral dis- placement of the tendon, usually to the ulnar side, occurs at the time of dislocation. Division of the Tendons in the Hand and Fingers. — Subcutaneous laceration of the tendons, more properly avulsion of the tendons, is of rare occurrence in the hand, and more commonly affects the extensors than the flexors. Of the latter, few cases have been reported. In the case of an extensor the avulsion takes place close to the insertion; owing to its partial fixation at the joint this tendon does not retract; it is usually held attached to the end-phalanx by several lateral fibres. A small piece of bone is often torn from the base of the end- phalanx with it. The production of the injury presupposes maximal flexion of the end-phalanx with extension of the second phalanx at the first interphalangeal joint. Suture is advisable for complete division; where the tendon is held laterally, immobilization of the end-phalanx in extension may conduce to the formation of fibrous union, but the restoration of function is seldom complete. In the much rarer subcutaneous laceration of the flexors a small fragment of bone is almost always torn off from the base of the end- phalanx. The injury is caused by active muscular contraction simul- taneous with passive hyperextension. Owing to its lack of fixation the flexor tendon retracts much further and forms higher up a palpable tender lump accompanied by loss of function. The treatment of this injury is much less favorable. The attempt to force the tendon down by bandaging the muscles of the forearm is usually futile; even suture is uncertain if the tendon is no longer held by lateral fibres. Still, these measures should always be tried or supplemented by plastic operation. In a case of Sick's the proximal stump was so turned upon itself that suture was impossible. Direct subcutaneous division of the tendon without other injuries can only happen' in consequence of very great violence produced by a blunt object without division of the skin. Very little has been reported in regard to such injuries, yet the functional loss resulting from the 282 INJURIES OF THE WRIST AND HAND. injury being overlooked and remaining uncorrected is lamentable with reference to the earning ability of the patient. According to the recent observations of military surgeons (Diims, Steudel ) , it would seem that the cases of pronounced functional disturb- ance of the extensor longus pollieis tendon known as "drummers' par- alvsis " are due to rupture of the tendon. The affection, beginning with the symptoms of tenosynovitis, causes destructive inflammatory changes in the tendon; a single sharp muscular contraction suffices to tear the loosened tendon. In 1881 Roberts reported such a case of genuine rupture; Diims has seen 2 cases, and Steudel proved the existence of rupture on operating. The site of rupture is always the point at which the tendon-sheath emerges from the distal border of the dorsal trans- verse carpal ligament. It cannot be denied that this circumstance is significant, considering the duration of the irritation and the very exacting, almost spasmodic use of this tendon in holding the drumstick. It is evident that if the correctness of this discovery can be verified, the onlv treatment of this "paralysis" is suture of the tendon. Open Division of the Tendons. — The author regards it as practical to describe this injury in connection with the technic of treatment, although naturally it is very frequently only a part of simple or complicated injuries of the hand and fingers. Division of the tendons usually results from incised or stab- wounds; the diagnosis is frequently made by the patient and it is not unusual for the latter to appear and state that the wound had been sewed up, but that he cannot move the end of his finger, so that the "bender" must be hurt, whereas the tendon had never been sutured. With proper attention it is hardly possible to overlook this important injury, if before beginning treatment every case is examined systematically in regard to function, circulation, and nerve-supply. The excuse that the extreme pain prevented examination is invalid, for even children can be made to attempt voluntary movements. On the other hand, division caused by stab-wounds, by metal or glass, particularly if the wound is small, may be regarded by the patient as too slight to require surgical assistance, and be first recognized on attempting to use the hand or fingers. Individuals with an occupation demanding fine finger-work are wont to seek infor- mation at once in regard to the seriousness of the injury, whereas others — servants — with equal frequency are indifferent about the injury for weeks, particularly if it involves one of the fingers of the ulnar border, fourth or fifth. Partial division of the tendons is easily overlooked; its functional significance is also slight. There is usually very little dis- turbance except that of diminished power. Treatment. — In general the following important principles are to be observed: 1. If the stumps of the tendons are soiled, they should either be cleaned up or the wound kept open for a few days until the question of infection and its severity is determined. 2. Where there is extensive laceration of the tendons and plastic measures are required to overcome the defects, the operation should not be done at first, but after the wound has healed. Plastic operations performed after months usually give ISOLATED INJURIES OF THE TENDONS. 283 primary union and better results. 3. If the proximal stump must be found, it is advisable to stroke the muscle forcibly downward, excep- tionally to bandage the muscles of the forearm downward as proposed by Rose, aided by Feli/.et's hook if the surgeon is dealing with the flexors, or to hyperextend strongly the adjacent lingers, by which the proximal stump is pulled down. 4. If the stump is widely retracted, prolongation of the wound in the direction of the tendon is the quickest and most certain way of reaching it. It should not be torn or lacerated, but tied with a loop of thread, which latter may be used for suture. 5. The technic should be simple; the suture material should be of small size and coaptate the surfaces of the tendon without impairing the circu- lation. In pulling upon the sutures the hand and fingers should be held in the position which relaxes the tendon. The wound may be closed, or small openings left with thin aseptic drains according to the danger of infection. 6. The splint should insure immobilization for three weeks. The position should be as comfortable as possible for the patient; for example, flexion of the middle finger with extension of the second and fourth cannot be endured very long, therefore better all fingers flexed. 7. In general, passive motion should not be begun before the end of the third week. Massage of the muscles of the forearm during this time is superfluous, and on account of the unrest of the patient jeopardizes the result. Modifications in individual cases are self- evident. In describing the injuries of the tendons the author desires to make clear the indications for treatment because' of the social significance of this injury with regard to the impairment of the earning-efficiency, and, further, because every surgeon should be in a position to carry out the technic even with limited assistance. If injury of the tendons is diag- nosticated, but the technical conditions for its treatment not available, the author would recommend as most profitable to the patient that the wound be covered — after ligating the bleeding vessels — with an aseptic dressing that will not smear the wound area and that the patient be re- ferred to an institution where skilful technic can be guaranteed, for inadequate treatment is often more dangerous and productive of more harm than failure to suture with the possibility of subsequent careful measures. The author employs the following technic: If the wound is large or several tendons involved, the patient is anaesthetized. On psychical grounds this is often better and usually guarantees greater care in all the details, as rapidity is not imperative. If the wound is slight, local anaesthesia may be employed. The region about the wound is cleaned in the usual manner and the skin sterilized with extreme care, a tiresome undertaking of twenty to thirtv minutes in the case of laborers. Accord- ing to the amount of bleeding — in fact, in the majority of cases — the Esmarch bandage is applied. The proximal stump can usually be drawn down by holding the hand and arm in the appropriate position and stroking the muscles downward. The bandage will rarely be required. After cleansing the wound and ligating, the proximal stump is transfixed 284 INJURIES OF THE WRIST AND HAND. T 3 ^ inch above the cut surface with a Hagedorn needle — and in the author's clinic without exception with silk suture — and the tendon held loosely by this thread. (Fig. 190, a.) In the manipulation the tendon is held carefully with tendon-forceps or a tenaculum (Figs. 18S and 189); the silk is passed in the same plane through the distal Fig. 1S8. c Tenaculum. stump and the suture left untied. A second suture is then passed perpendicular to the former \ inch from the edge through both stumps; thread a is then tied, then thread b somewhat looser to avoid displacing the apposed surfaces. One suture is usually sufficient for small tendons, Fig. 189. Tendon forceps. in which case the author sutures a little farther from the end, about j 5 g- inch. This suture is simple, quickly performed, and certain. If it is necessary to freshen the tendons the author always cuts them squarely off, never obliquely; he never affixes to the adjacent tissues. As stated, Fig. 190. Tendon suture. the wound is always closed primarily if possible, or small drains left between the skin sutures if necessary; it is never left open, rarely drained from the bottom. The author always uses three-ply twisted English silk — No. 00-1. Primary union without ejection of "aseptic" threads was obtained in 15 cases, in each of which several tendons were sutured. ISOLATED INJURIES OE THE TENDONS. 285 Three cases of plastic flap operation were equally successful. Numerous instances of suture of single tendons gave like results. No mention of or apology for the occasional infection accompanying the injury is needed. Many infections can be checked by inserting several small drains between the skin sutures. Immobilization for flexor injuries is always by means of a moulded, well-padded plaster splint applied on the dorsum with the hand flexed; by means of straight pasteboard splints for injuries of the extensors; by means of a plaster strip moulded on the flexor surface with marked Fig. 192. Tendon suture methods: a, Wiilner; b, Hagler; c-f, Trnka. dorsal flexion of the hand if all the extensors are involved. It is an operation which the author likes to perform without assistance — with the exception of the anresthetizer — before students. If infection occurs, the skin suture should be loosened; the result of the tendon suture is thereby almost always jeopardized. If recovery is uninterrupted, the first bandage is changed on the tenth to the fourteenth day. The author has often allowed it to remain until the third week. He never begins massage, passive motion, etc., until the end of the third week, for few cicatrices are under such unfavorable circumstances for holding as those of the tendons — slow proliferation of connective tissue, scant formation 230 INJURIES OF THE WRIST ASD HAND. of vessels, constant traction. At the end of this time motion may be begun and massage adjacent to the wound, electricity and massage applied to the corresponding muscles, and after four weeks active motion begun. For division of all the flexors and extensors, the author prefers absolute immobilization for five weeks with the chance of adhesions, the latter often being entirely overcome by prolonged treatment. The author should not omit to mention the methods of treatment used elsewhere. Xicoladoni recommends drawing down the proximal stump with a tenaculum. This method does not always give the desired result, sometimes produces secondary injuries, especially of the tendon- sheaths, and may tear out the tendon or fray out the stump. Madelung proposed to hunt for the retracted stump through an incision proximal to the wound, to slip a loop of thread over the stump and draw the former into the wound with a probe. If the tendon is found, subsequent prolon- gation of the wound is unnecessary, an unmistakable advantage in appro- priate cases. The prolonged incision necessary to reach the proximal stump is made by Witzel at the side of and parallel to the tendon, to prevent the suture-line from lying upon the tendon suture. This propo- sition is founded upon the fact, reported from Billroth's clinic by Schussler, that the wounds are often under great tension on account of the necessary immobilization, as the result of which transverse wounds are usually (edematous; so that, even where the course is smooth, con- siderable cicatricial tissue is formed and extends to the tendon. Whether this can be obviated by a lateral incision remains undetermined. Special fixation measures — provisory suture of the tendons (Xicoladoni), fixa- tion sling (Witzel) — are hardly necessary. The most important details of the teehnic are those given by Wolfler, Tmka, and Hagler, as shown in Fig. 192. For plastic operations on the tendons, see page 37o. FRACTURES OF THE LOWER END OF THE RADIUS. Fracture at the Classical Spot; Typical Fracture of the Radius; Colles' Fracture. Fractures at the junction of the middle and lower thirds are not much more frequent than those of the middle or upper third. They were described in Chapter XIV. The so-called "typical" fracture of the radius has quite another practical importance. The more closely it is studied, the more the idea of "typical," at least with reference to the anatomy, disappears. The details of the fracture are manifold, and the typical repetition of the variety is lacking in a large number of cases which are classified clini- cally as "typical" fractures. Xevertheless the symptom-complex with reference to the etiology and clinical course of the injury has repeatedly so much in common that it is advisable on practical grounds to retain the chosen term. (Colles, v. Volkmann.) FRACTURES OF THE LOWER END OF THE RADIUS. 287 The history of the injury is rich in interesting details. It is a curious circumstance that it was almost unknown at tlu- beginning of the nineteenth century, so that Colles, the Scotch surgeon, was able to publish the first accurate report in L814. As a result the names of distinguished German, French, English, and American surgeons are found connected with the pathology and treatment of fracture of the radius, a good illustration of its great practical importance. As fracture of the radius takes first place in frequency among all fractures of the hones, according to Goyrand almost a third, according to Malgaigne 10 per cent., according to v. Brims ( .U'> per cent., and its significance with reference to the use of the hand is so evident, it would he idle to waste further words in regard to it. By the introduction of the accident laws in Germany it has acquired an especial prognostic position. The treat- ment may present such difficulties and annoyances, even where all details are carefully regarded, that often only inexperience can excuse rash criticism of the results accomplished by others that is made without accu- rate knowledge of the relations appertaining to each individual case. The injury, to anticipate, is by no means to be regarded as harmless as it appears from many representations, particularly in old age, so that it seems to us to be a special duty to discuss not only all the derails of the recent injury with respect to the therapeutic indications, tat also the diverse modifications of the prognosis. By typical fracture of the radius — loco classico — is understood an isolated fracture of the bone, usually transverse, about f to 4 inch above its distal end, with displacement of the distal fragment backward and usually outward, and frequently with corresponding displacement of the wrist. It almost always results from a fall upon the volar surface of the outstretched extended hand. Mechanism of Origin. — The clinical symptoms can be grasped most rapidly if the mechanism of origin is considered. The possibility of producing a fracture in a long bone is known to increase with the distance of the lines of direction of the forces from the bone (a generally applicable law of fracture). The forces concerned in fracture of the radius are as follows: by falling upon the palm of the extended hand, the carpus, by reason of the solidity given by its liga- ments, is pushed as a solid body against the posterior edge of the radius. The force exerted by the counteraction of the ground against that part of the weight of the body thrown upon the wrist is transmitted to the carpus, which in turn, as a solid, unyielding mass, transmits this force undiminished to the radius. Resistance of the ground, part of the body-weight, velocity of the falling motion, are the components of this first force. Simultaneously the firm anterior ligament 1 is put on the stretch, which, after exhaustion of its 'physiological elasticity, opposes 1 According to Henle. the ligamentum carpi volare profundum arcuatum, radiatum, and trans- versum; according to the more recent nomenclature (W. His, "Die anatomische Nomenclatur," Archiv f. Anat. u. Physiologic Supplement band 1895, p. 42) ligamentum radiocarpeum volare which spreads out from the styloid process and anterior margin of the carpal articular surface of the radius into several bands running to the scaphoid, lunar, cuneiform, and os magnum. 288 INJ CRIES OF THE WRIST AND HAND. Fig. 193. the first force specified above by pulling upon the radius. It is more resistant than the bone, so that the latter breaks more easily than the ligament tears. The lower end of the radius is therefore broken off by pressure and by traction. (Fig. 193.) The exclusive action of a blow or a tear is usually out of question; considered mechanically, both forces must act to produce the fracture. The effect of the force is the same whether a body is set in motion or a moving body is arrested; in both cases the possibility of a solution of continuity increases with the velocity. The same force could be applied to the radius without producing frac- ture, if the increase were gradual. The velocity in falling is accordingly of great importance, but it is rarely possible to form an accurate judg- ment in regard to it. In like manner the velocity with which the force is transmitted determines the site at which the force is manifested: the more rapid the transmission, the closer to the point of application will be the effect of the force. That the fracture can result in the distal end of the radius and not at its middle is explained by purely mechanical laws, the analysis of which is beyond the scope of the present description. In falling, the patient unconsciously pronates the radius more or less for- cibly to support himself. Whether the fragment, in being displaced backward, will be pushed at the same time laterally (usually outward), will depend upon the degree of pronation at the moment ; the fragment will sometimes be arrested in semipronation by the contact of the hand with the ground, and the resistance of the same, while the radius is still further pronated — i. c, the lower fragment is forced against the upper in supination. Backward displacement, usually accompanied by shortening of the dorsal axis of the radius, and slight lateral displacement of the lower fragment necessarily produce lateral deviation of the wrist and hand, generally abduction (radial inflexion). From the above description it is easy to understand how the continua- tion of the force at the moment of fracture can produce impaction of the fragments in a large number of cases; the shaft of the radius is forced farther forward and displaced against the lower fragment as the latter slips backward, so that its posterior edge is impacted against the anterior Typical fracture of the radius. Backward displacement of the lower fragment. FRACTURES OF THE LOWER END OF Till-: HAD lis. 289 edge of the fragment. By a fall upon the dorsum of the Hexed hand — therefore with the hand in the opposite position — the forces mentioned work in the opposite direction. In this case the posterior ligamenl assumes the role played by the anterior in the typical fracture and pulls upon the posterior edge of the lower border of the radius, while the carpal bones press against the anterior edge and transmit the blow. The fracture-line runs in a characteristic manner in the opposite direction, distal-dorsal to proximal-volar. The distal fragment is displaced for- ward correspondingly if displacement occurs, and pushes the upper fragment backward. As in this fracture the effect of the effort to gain the support of the forearm is absent, there is no movement of pronation; the blow overcomes the flexion and impaction results almost without exception (not infrequently with comminution). Anatomical Findings. — The above mechanical factors produce the typical fracture of the radius. The anatomical findings on autopsy and operation give less information than examination on the living subject; the recent contributions of the x-ray and of experiments have been valuable. Kahleyss and Oberst have carefully sketched a composite picture of the injury as filled out by the a,- ray. For the anatomical description it is practical to distinguish from a therapeutic and prog- nostic point of view separation at the epiphysis, complete and incomplete fracture and fissures (the so-called typical contusion). It is not correct to designate the fracture simply as an epiphyseal fracture. A pure separation of the epiphysis is not seen after the eighteenth year, whereas the greater number of injuries occur between the fiftieth and sixtieth years. Separation of the epiphysis in children is not rare. (Helferich.) The fracture-line almost always begins at the epiphyseal line on the flexor side, follows the line for a short distance and then runs obliquely through the shaft to the posterior surface, so that a larger or smaller jagged fragment of the shaft is attached to the edge of the epiphysis, usually widest toward the posterior surface. (Kahleyss-Oberst.) How far the periosteum is separated from the epiphysis, as cited by v. Bruns, can hardly be determined by palpation. O. Wolff regards pure epiphyseal separation confined sharply to the line of growth as the rule. The frac- ture-line is commonly extra-articular and lies \ (Smith) to H (Colles, Hamilton) inches, usually f to 1\ inches (Dupuytren, Konig), above the point of the styloid process. (Fig. 194.) The more recent investigations with the x-ray indicate that it is between § and £ inch. Bardenheuer states rightly that this distance varies within rather wide limits, according to the side on which the fracture is examined and with the obliquity of the fracture-line. The distance from the joint is usually less on the anterior than on the posterior surface, namely, the surgeon is dealing with a fracture-line running obliquely, distal-volar to proximal-dorsal. For the reversed fracture-line caused by falls upon the dorsum, see the latter part of the section on Mechanism of Origin. If the distal fragment is displaced, it may be pushed backward and upward in the direction of the shaft; or, it may be rotated backward about its radio-ulnar axis. It is frequently displaced outward at the Vol. III.— 19 290 INJURIES OF THE WRIST AND HAND. same time. If the ulna is uninjured, the hand is abducted at the wrist (radial inflexion). (Fig. 196.) If the fragment is held by the cartilag- inous disk, it may be rotated about its dorsovolar axis with apparent Fig. 194. Fracture-lines in Colles' fracture (diagrammatic). (Kahleyss-Oberst.) displacement toward the ulna; more properly, it is torn off with the ulna. Actual rotation toward the ulna is exceptional. (Hoft'a.) Frac- tures in which the fracture-line penetrates in the same direction but obliquely into the joint are rare. The author has seen only 2 such with PLATE VI. Recent Comminuted Colles' Fracture, with Longitudinal Fracture Involving the Joint, and Marked Abduction. After Reduction. (Solley.) FRACTURES OF THE LOWER END OF THE RADIUS. 291 the .r-ray. This variety was first described by J. Rhea Barton. Lenoir was forced to admit that a case diagnosed as backward dislocation of the hand was such a fracture, in which the entire wrist followed the backwardly displaced fragment. In incomplete fracture, namely, infraction, the fragment is still attached to the shaft by its anterior portion and is rotated about the transverse diameter of the shaft at the point of fracture, so that its lower end tilts backward. If the lower fragment is comminuted — as is often seen in old age, rarely in childhood or middle age — the transverse fracture is combined with a longitudinal fracture entering the joint. (Plate VI.) The author has only been able to find this injury pronounced in 2 patients by means of the x-ray; one was a woman, aged twenty- eight years, who had fallen upon the extended hand, the other a man, aged thirty-two years, the hand having been flexed. In older individuals, as mentioned, it is more frequent. The transverse fracture-line is often somewhat angular, the angle pointing downward, a sort of Y-fracture; the outer portion is usually larger than the inner. These comminuted fractures are often impacted; the anterior edge of the upper fragment usually in the lower. Voillemier reports such an impaction, the lower fragment being broken into four pieces. The "palpable" fissures of the radius described by older authors are shown by the .r-ray to be usually fractures without displacement. In 48 recent fractures of the radius Kahleyss saw only two such, both from a fall upon the dorsum of the flexed hand. In a series of 50 x-ray pictures of fractures of the radius the author has never seen a pure fissure. In the mildest form the fine cleft penetrates, according to v. Brims, only through the joint-cartilage to the spongiosa. In the more extensive form it reaches obliquely or axially deeper into the epiphysis, or more or less into the shaft. Hamilton reports a star-shaped fissure. The clinical significance of fissures is in the involvement of the radio- carpal joint. Fissures are usually seen combined with fracture. The most frequent injury accompanying fracture of the radius is frac- ture of the styloid process of the ulna; that of the ulna itself is less com- mon. In 104 fractures of the radius, C. Beck found fracture or fissure of the head of the ulna in 25 instances, of which 31 per cent, were frac- ture of the styloid process. In contrast to the preceding, Kahleyss and Oberst place fracture of the styloid process of the ulna at 78 per cent. The author's observations correspond more to those of Beck. The fragment varies in size up to that of a bean. Simultaneous contusion of the carpal joints is of great prognostic importance. Injury of individual bones of the wrist with fracture of the radius was formerly seldom diagnosticated, and was based chiefly on supposition. Bardenheuer believes that there is often simultaneous fracture of the scaphoid; Gocht and Kahleyss have seen it twice. The author has also seen 2 cases. Simultaneous fracture of the os magnum has been seen by Bardenheuer in 3 instances; by the author once. Destoit and Gallois report the same of the unciform; Kahleyss once saw fissure of the scaphoid and once fracture of the same. Authentic 292 INJURIES OF THE WRIST AND HAND. instances of accompanying dislocation only concern the scaphoid, according to the author's review of the literature. Important are, finally, the comminution of the cartilaginous disk, avulsion of the same, and contusions and fissures of the cartilage in the radioulnar joint. They may cause subsequent pain, functional loss, and joint-deformity. Symptoms. — The patients often come to the surgeon immediately after injury, supporting the arm in every change of position after they have Fig. 195. ^gl^^H Backward displacement (silver-fork deformity) in Colles' fracture. learned that movement and jarring produce pain. The point of greatest pain is often sharply localized. Pain may be slight with impaction, increased if the joint is involved. A localized point of tenderness on pressure is always present, and is often the most important symptom if there is merely inflexion or impaction; the characteristic spot is f to 1 inch above the styloid process. In active movements flexion and exten- sion are greatly limited, pronation and supination usually lost. Even Fig. 196. Silver-fork deformity of Colles' fracture. the elbow-joint is moved reluctantly by the patient, especially by children. The power of the hand is greatly diminished; the comfortable position for the fingers is three-fourths extended. The above symptoms are the rule; still with impaction, pronation and supination can sometimes be carried out slowly — never to the normal extent — and apparently without pain, particularly by elderly women, in whom this injury is most fre- quent. FRACTURES OF THE LOWER END OF THE RADIUS. 293 Diagnosis. — The diagnosis is often made by inspection. The deformity is usually more or less typical, although it may vary greatly. In doubtful eases compare with the sound arm and inspect the arm on all sides. The most striking change at first glance is the broadening at the wrist; where the displacement is pronounced — it is even recognized by the laity — the lower fragment projects backward, and the cud of the shaft presses against the flexors. (Fig. 195.) In consequence of the retraction of the lower fragment and the shortening of the radial axis the hand is abducted. (Fig. 197.) On the posterior surface above the joint a promi- nence is seen corresponding to one on the anterior surface less pro- nounced and farther from the wrist. This prominence gives a characteristic outline to the extremity, the silver-fork deformity. (Fig. 196.) Lateral displacement of the hand, namely, abduction and projection of the ulna on the other side, produces a typical deformity, termed bayonet-deformity. (Fig. 197.) The backward displacement of the fragment which articulates with the carpus supinates the hand, the shaft of the radius being pronated. Fig. 197. S> ^ Marked abduction (bayonet deformity). On palpating the posterior surface, if necessary by displacing the blood-clot carefully, the edges of the displaced distal fragment can be felt. The index finger passing over the lower end of the radius upward toward the shaft sinks into a depression immediately above the fracture, namely, above the upper edge of the lower fragment. On the anterior surface, although the tendons may make palpation difficult, the edge of the frac- ture can be felt by passing the finger along the radius from above down- ward. Mobility of the lower fragment is recognizable in only a small percentage of the cases, and in like manner crepitation is not obtained without further manipulation. The projection of the lower end of the ulna on the ulnar side can frequently be seen and felt, and the patho- logical displacement verified by comparison with the sound arm. If the styloid process of the ulna is broken off, pain on pressure is also obtained here. In the majority of cases the changes are not so conspicuous or easily felt. Radial deviation of the hand is then recognizable only by careful comparison and inspection of the posterior surface from above. It should be mentioned that, on inspecting from the radial side, a symptom is usually evident, the importance of which has been empha- sized by Konig: normally from this point of view the radius, especially if pronated, shows a slight curve convex toward the posterior surface. In fracture this bowing is absent, even if the displacement is slight, or 294 INJURIES OF THE WRIST AND HAND. the curve is in the opposite direction. (Fig. 195.) Recognition and due appreciation of this sign never leave one in doubt and are of great diagnostic value even in the slight displacement of typical fracture. As the larger number of cases are impacted fractures (Diday, Callen- der, all recent authors), it would be a mistake to attempt to elicit crepitus by force. By palpation, as mentioned, crepitus is not usually obtainable. In determining the value of the localized pressure-pain it is a good rule to approach it from the adjacent parts of the radius. If localized h to 1 inch above the end of the radius, it is pathognomonic. It is obtained better by proceeding slowly, pressing with the end of the index finger, than by grasping indiscriminately with the entire hand. [An even more delicate test is to use the edge of a rule, end of a lead-pencil, etc.] If the examiner merely obtains pain on pressure, and the same is pronounced at the foveola radialis (tabatiere anatomique) he will sel- dom err in assuming an isolated fracture of the styloid process of the radius. The author has seen this injury rather frequently. He does not resort to the x-ray for volar dislocation of a single bone of the wrist not associated with fracture of the tip of the styloid process, but assumes the existence of this isolated dislocation from the preponderance of the tear- ing force, which by maximal hyperextension may so act that the wrist slips under on the anterior surface instead of pressing forciblyagainst the radius. Comminution and fissures can be presumed rather than palpated with certainty, in which case the diagnosis will depend upon the x-ray. The same applies to the simultaneous involvement of individual bones of the wrist. A fracture or dislocation of one of these bones may be presumed from pain on pressure or abnormal prominence, exceptionally from crepitus; still, a definite conclusion as to the details will hardly be possible without the x-ray. Injuries of the disk (Nelaton) are recognizable by passive supination and pronation, if not by direct palpation (crepitus); also by false motion and projection of a movable fragment of cartilage. That this cartilage is frequently involved is explained by the mechanism of the injury. The extent of involvement is not always easily determined; occasionally at the site of the cartilage there may be merely pain on pressure lasting for some time; or slight crepitus; or the signs of beginning arthritis deformans. These symptoms make injury of the disk probable. The radio-ulnar joint closed off by the disk may be severely injured without evident lesion of the latter. The injury, if recent, may be manifested merely by effusion; later, pronation and supination, flexion, and extension may be impaired for a long time by reason of the pain produced and the existence of deforming processes. In like manner the radiocarpal joint is often severely contused without apparent fracture of any of the carpal bones. Long-standing effusion followed by connective-tissue growths in the synovial membrane, thickening and shrinkage of the latter, and secondary impairment of motion, are the accompanying and resulting symptoms. A rare associated injury, to which the author has never found reference made, and the presence of which he has often regarded as probable on PLATE VII Recent Colles' Fracture in a Boy Twelve Years Old, showing Epiphyses. (Stimson.) FIG. 2. Old Fracture of Radius and Ulna, with Reversal, Overriding, and Weak Callus. (Solley. ) FRACTURES OF THE LOWER END OF THE RADIUS. 295 account of the great sensitiveness of the base of the second metacarpal and the impaired pronation of the hand, is the overstretching, tearing, or avulsion from its insertion of the tendon of the extensor carpi radialis. In the differential diagnosis the rare backward dislocation of the wrist is to he considered; for it and against fracture are the complete con- tinuity of the radius to the tip of the styloid process; the absence of sensitiveness along the bone; lack of crepitus and of radial adduction of the hand; the prominence of the curved articular surface of the upper row of carpal bones and the flexed position of the hand. The diagnosis between infraction, impaction with slight shortening and contusion is sometimes more difficult. Careful palpation of the continuity, examina- tion for points of tenderness, and for slight widening and inflexion of the lower end of the radius; in short, the critical analysis of the above diagnostic signs, will hardly allow the conscientious examiner to make a wrong diagnosis. Treatment. — The first principle of treatment is to reduce all recog- nizable displacements. If the backward displacement of the lower frag- ment is pronounced, the middle of the forearm of the patient is grasped with the left hand and the thumb or index finger used to control the frag- ments. The hand is grasped at the metacarpus with the right hand and quick and increasing traction is exerted in the axis of the forearm. With this grip many displacements can be reduced completely ; doubtless it will often require simultaneous traction in the sense of forced flexion and pro- nation, for, as has been seen, the lower fragment is pushed back in supina- tion at the time of injury, while the rest of the radius is forcibly pronated. The author approves of combining flexion and pronation, as the hand is thus brought into the best position for maintaining the reduction in the splint. The desired effect is obtained maximally by pronating and finally adductiug the hand. (Cline, Dupuytren.) If reduction fails in this way, forcible extension (dorsal flexion), as em- ployed by Roser and recently recommended by Konig, followed again by traction, as mentioned above, may succeed. For fracture caused by a fall upon the dorsum of the flexed hand, the manipulation will be in the opposite direction. If in impacted fractures there is displacement and marked radial deviation of the hand, the author is careful to obtain proper correction by loosening the fragments and manipulating until suc- cessful. Herein lies the salient point of treatment. Non-recognition and non-reduction of the displacement may be accompanied, under circumstances, by very serious results. The author often uses anaesthesia. If assistance is employed, the operator has both hands for traction and manipulation, the assistant exerting countertraction upon the elbow and upper arm. Extension is facilitated over a fulcrum, namely, over the knee or a sand-bag, book, block of wood, or the edge of a table. The extent of manipulation and the entire teehnic employed depend upon the amount of displacement present. In pronounced oblique fracture as well as in transverse fracture, there is a great tendency for the displacement to return if the surfaces of upper and lower fragment are not entirely apposed. After reduction 296 INJURIES OF THE WRIST AND HAND. the line of continuity of the radius should be unbroken. Isolated fracture of the tip of the styloid process does not require reduction, just as fracture of the same process of the ulna does not need special measures. If the ulna is displaced outward to any extent after rupture of the cartilaginous disk, the correction of the deformity is often incom- plete. Dislocation of single carpal bones will be overcome if possible (often without the desired result) in case of forward dislocation by extreme extension. The author established above why the reduction is best maintained by supinating the shaft of the radius and flexing and adducting the hand. For this reason this position should be sought as the ideal one. The author is guided personally by the experience that a properly applied plaster-strip splint insures this position most accurately, and is therefore to be recommended where there is a tendency to displacement. One or two plaster roll bandages are soaked and laid out upon a flat surface by folding back and forth, the length of the strip corresponding to the distance from the heads of the metacarpals to the middle of the upper arm. The layers are built up to the proper thickness by using one or two rolls, smoothing down each successive layer. A piece of flannel is then cut about § inch larger on all sides than the plaster strip; the strip is then laid upon it, and with the flannel side toward the skin it is applied to the flexor surface — rarely extensor surface — of the fore- arm, reaching from the middle of the upper arm to the heads of the metacarpals; it is then bandaged with muslin or flannel roll bandages, the arm being held by an assistant. If necessary, the arm can be manipulated after the splint is applied, to obtain the proper position. If the tendency to displacement is slight, the splint may stop at the elbow; but where it is desired to immobilize the entire radius the elbow- joint should be included. The splint is thus adaptable to the individual case, leaves one side of the arm free for inspection and for the circulation, and is comfortable. The renewal of the splint depends upon circum- stances. The author often leaves it in position from two to two and a half weeks until consolidation has advanced to the point where absolute fixation is no longer necessary. Massage about the fracture and joint on the free surface can begin on the sixth to eighth day. As especially emphasized by Schede, it is very important to leave the fingers out, particularly in elderly individuals. Quite properly the circular plaster splint is no longer used by most surgeons for recent injuries. If it is not well padded, the bad results — ischemic paralysis, persistent joint disturbances, etc. — -are not excluded; if it is well padded, it does not meet the indication for which it is applied. There is no objection to its application after the blood extra vasate has subsided. Of the numerous other methods of using strips, only those will be mentioned that have been well tested. The practice and custom of the individual will determine the choice of this or that method. With the proper selection there are many roads to success, for the time has passed when every new observation of fracture of the radius would lead to a new splint. The picture of the injury stands finished before the surgeon ; FRACTURES OF THE LOW Ell END OF THE RADIUS. 297 the simpler the appropriate method is, the greater its claim for recog- nition. ( )n the grounds of a wide experience, Konig recommends Roser's posterior splint with a pad on the hack of the hand. (Fig. 198.) "A splint about the width of the arm begins at the external condyle and extends at least to the first phalanges of the fingers. Naturally it is well padded. It is so applied to the hack of the arm and the hand that the hand is allowed to hang down in flexion. The splint is thus in contact Fig. 19S. Roser's splint for Colles' fracture. with the arm only to the wrist; the free space beyond to the fingers is filled in best with firm graduated linen compresses, so applied as to form a wedge. The tapered end lies directly upon the lower backwardly displaced fragment. The fingers are left free in order that they may be moved while the splint is in place. The entire arm down to the fingers is now bandaged with flannel firmly against the splint. The dorsal pad thus Fig. 199. N(51aton's pistol strip. presses against the projecting lower fragment. The tendency of the upper fragment to become displaced is prevented by its being drawn tightly against the posterior splint above the pad. If, however, the upper end still shows a tendency to forward displacement — which, by way of digression, has never happened in the author's experience — a short anterior splint may be added, reaching to the wrist, with a pad above the wrist." Another posterior splint often used is Nelaton's pistol strip. (Fig. 199.) 298 INJURIES OF THE WRIST AND HAND. The most adaptable, and for this reason the most advisable, splint for the practising surgeon is Schede's anterior strip. (Fig. 200.) Gutter splints of metal or wood are recommended by Dupuytren, Chelius, Blandin, and Goyrand; recently for ulnar application by Kolliker. It Fig. 200. Schede's anterior strip splint. Fig. 201. should not be omitted that the experienced Roser has abandoned all splints that merely adduct the hand and wrist. The treatment of fracture without splints has recently found several advocates. Helferich recommends Storp's suspension-cuff (Fig. 201): "After reduction is accomplished, the hand is brought into extreme adduction and flexion (ulnar- volar flexion); a strip of adhesive plaster about 4 inches wide is wound several times around the lower end of the forearm down to the styloid process; a second strip forms a loop over it on the poste- rior surface, to which a sling is fastened. The author places the suspension loop midway between the side and back of the radius, so that the suspended hand hangs down toward the ulnar and volar surface." Faenger places the arm upon a double-inclined plane, the flexed wrist lying on the ridge. Petersen recommends as the best method for fracture of the radius that the hand be allowed to hang over the edge of a carrying-cloth in adduction ; this suffices to hold the fragments in the proper position. Konig and Bardeleben have warned against the generalization cf this method, quite properly it appears to the author. At an earlier period Storp's suspension-cuff. (Helferich.) FRACTURES OF THE LOWER END OF THE RABIES. 299 Velpeau objected urgently against such experiments, for in the first place this method presupposes on the part of the patient an amount of intelli- gence which does not appertain in the average case. In the event of failure the attending surgeon is nor .-pared reproach for treatment com- parable to "almost none." Even the sensitiveness of the patients can frequently make its application impossible. After-treatment and Prognosis. — In general, the statement is correct that typical fracture of the radius, by appropriate treatment and in the absence of functional disturbance resulting from callus, recovers in from two to four weeks. In young subjects this is almost without exception; Fig. 202. Plaster-of-Paris splints for Colles' fracture. (Stimson.) in men of the laboring classes, especially those who bask in the light of accident legislation, the author does not see the full use restored before the sixth to eighth week. In old age the fracture often requires special care. As mentioned, the author leaves the first splint (plaster-strip splint) on from ten to fourteen days, ordinarily without aiding resorption of the extravasation by massage on the free surface during this time. Later the patient returns daily or every other day for one or two weeks for massage and movements, if the condition of the fracture warrants. The splint is Fig. 203. Wooden splints for Colles' fracture. (Stimson) still worn during this time and removed during the massage, or is later replaced by a lighter splint. Meanwhile the wrist is flexed and extended passively, the arm is carefully pronated and supinated, and all the finger-joints exercised passively. During this time massage is essen- tial for early return of function if there is extravasation in the wrist or about the fracture. If on first removing the splint displacement still exists, reduction by manipulation is unconditional. Frequently simultaneous contusion of the carpal joints and injuries of the radio-ulnar joint, sometimes combined with injury of the car- 300 INJURIES OF THE WRIST AND HAND. tilaginous disk, give trouble for a longer time than the fracture itself. More or less severe deforming processes in the joints involved are not rare up to the fiftieth year in spite of careful after-treatment; particularly adhesions of the flexor tendons caused by cicatricial contraction of the sheaths after long-standing effusion, adhesions due to growth of callus, and the secondary motor disturbances of the fingers, demand constant attention. All measures, such as protracted water- or sand- baths, used in connection with massage, and the movements aiding circulation and resorption, are meanwhile to be employed if warranted by the subjective condition of the patient. Nevertheless the author sometimes sees long-continued impairment of motion followed by atrophy of the muscles concerned, particularly in elderly women, and especially if sensitiveness demands absolute immobilization for a greater length of time or if motion or massage is refused by the patient. Up to the sixth month secondary reduction may be indicated by deforming callus or union with displacement; after this, osteotomy, either of the radius alone or also of the ulna, is to be considered. For synostosis forming between the radius and ulna, resection of the capitulum of the ulna is proposed by Lesser and has been done successfully by him and by Lauenstein. Pseudarthrosis is rare. FRACTURE OF THE CARPAL BONES. The bones of the carpus are so fused together by the posterior, anterior, and intercarpal ligaments that it is often difficult to determine by palpation where the fracture lies. All fractures of the carpus presup- pose marked direct or indirect violence, so that we usually find likewise severe injuries of the soft parts. The latter easily conceal the signs of fracture and previous to using the .r-ray one often has to be satisfied with a probable diagnosis of fracture. Pain, usually intense, severe functional disturbance, and marked extravasation of blood support the diagnosis. Bony ankylosis, recognized subsequently in the absence of fracture of the radius, is almost always the result of fracture of part of the carpus. The fracture involves commonly only a part of, very rarely the entire, carpus. The author has repeatedly seen simultaneous fracture of the os magnum, unciform, and lunar produced by a blow. Indeed, he regards these bones as the ones predisposed to fracture, considering the nature of the forces usually concerned. Occasionally the scaphoid is also involved; more commonly it is fractured by the force producing fracture of the radius, or it accompanies the latter. The diagnosis of isolated fracture of single carpal bones presents about the same difficulty, although local crepitus may be of assist- ance. The injury is apt to be accompanied by severe laceration of the soft parts, especially the ligaments, and then has an unfavorable prognosis. Heavy manual labor is often impossible for a long time. The scaphoid and pisiform are the most frequent examples of isolated > < CL < DISLOCATION OF THE WHIST. 301 fracture. The pisiform is broken by a fall upon the extended hand; occasionally there is simultaneous laceration or avulsion of the flexor carpi ulnaris and corresponding functional loss. Fracture of the scaphoid results indirectly from a fall upon the outstretched hand while strongly extended, abducted, ami pn oated forcibly. (Plate VIII.) The steps of the injury are usually described as similar to those of fracture of the radius. There may he distinct localized crepitus below the radius. In an analogous manner the cuneiform is broken if the hand is ad- ducted at the moment of injury. Direct violence, particularly a shot- wound, may affect all the carpal bones, in which case the diagnostic evidence is so pronounced that it can be scarcely overlooked. Treatment. — The first object of treatment is to alleviate the severe pain. The author has repeatedly aspirated large hemorrhages in the joint. Actual comfort is obtained by absolute immobilization upon a straight splint and by use of the ice-bag, and is increased by elevating the hand. At the end of several days, massage, and later passive motion, should be begun. Ankylosis sometimes occurs, and its later removal causes renewed severe pain. At about the second week compression and warm baths are well borne and hasten recovery. Early active use, as soon as the pain allows, is desirable and should be gradually increased. DISLOCATION OF THE WKIST. Dislocation of the wrist, at an earlier period frequently included in and confused with the diagnosis of fracture of the radius, is supposed to have been relegated to the realm of pure phantasy by Dupuvtren's extreme point of view. This is opposed to the facts, as dislocation of the wrist is a positive although extremely rare observation. Dislocation of the entire carpus upon the forearm, backward as well as forward, has been seen. It is sometimes complicated by fracture of the styloid process of the ulna. Fracture of part of the joint-surface of the radius has also been seen with it. (Parker.) YViessner reports a bilateral injury in a boy fourteen years old who had fallen from a height. The difficulty in the production of the injury is due to the strength of the posterior and especially to the even stronger anterior ligaments. Violence, chiefly direct, acting upon the dorsum may cause the for- ward dislocation. The more frequent dislocation backward upon the bones of the forearm may result from a fall upon the back of the hand while it is hyperflexed. In both cases the relation of the styloid processes to the carpus is decisive for the diagnosis: in dislocation without simultaneous fracture they must lie in the prolonged axis of the radius and ulna. (Fig. 204.) In backward dislocation the proximal part of the carpus lies upon the lower ends of the bones of the forearm and lifts up the extensor tendons. On the flexor surface the ulna and radius project correspondingly, the styloid processes being easily felt. They can protrude between the flexors and the adductor pollicis longus and perforate outward through the fascia and skin. Occasionally the articu- 302 INJURIES OF THE WRIST AND HAND. lar surface of the radius can be felt on the flexor surface. The promi- nence on the posterior surface is much more abrupt than in fracture of the radius; it includes the entire width of the back of the hand and its curved border, convex upward, can be felt plainly by careful palpation. The axis of the hand usually shows no deviation from that of the fore- arm; the hand is flexed slightly — in forward dislocation it is extended slightly— and the fingers are semiflexed at the metacarpophalangeal joints. There is no difference in the length of the hand compared with the sound one, or in the length of the radius or of the ulna from the olecranon to the styloid processes; still, the distance from the olecranon to the tip of the middle finger is evidently shorter compared with the sound side. This shortening can only be explained by displacement at the wrist- joint. The avray will remove all doubts as to the condition. Fig. 204. Backward dislocation of the carpus. Treatment. — Reduction is usually effected quickly by traction and flexion in the same direction in which the injury was produced. The functional prognosis is doubtful, however, on account of the injury of the soft parts. There is also a tendency to recurrence. It is a good plan to immobilize the hand for a short time — in backward dislocation slightly extended, in forward dislocation flexed — in order to approxi- mate the torn ligaments as much as possible; further, to maintain the carpus in position by the moderate pressure of a pad. Resection will be necessary only exceptionally where reduction is impossible on account of the hindrance caused by portions of the carpus or where the injury is of longer standing. Habitual and voluntary dislocation of the carpus upon the forearm has been seen. Little is known of post-traumatic habitual dislocation on account of its rarity; still we find statements of "recurrence" of the dislocation during the first weeks after the injury. A case of voluntary forward subluxation came under the author's observation. The patient concerned, a young surgeon, had the full use of his left hand, but was able at will, without the assistance of the other hand, to produce the dislocation with a snap. The prominence of the extensors caused by the forward displacement of the carpus was very characteristic. He was also able to dislocate the left thumb and both tibias at the knee. The dislocations never occurred involuntarily. Madelung has described in detail a subluxation of the wrist seen at times in young seamstresses. DISLOCATION OF THE WRIST. 303 If the capsule is relaxed, severe handwork soon produces a forward dislo- cation of the wrist; the ulna and radius are displaced backward. During the development of the lesion extension of the hand is very painful. Although reduction is impossible, strengthening the muscles and the proper kind of work improve the condition. Intercarpal dislocation of the second row upon the first (luxatio medio-carpienne of Malgaigne and Depres), both forward (Malgaigne, Bardenheuer) and backward (Maisonneuve), have been reported.. Mechanical force or a fall from a height are given as the causes. Till- manns reports an incomplete anterior intercarpal dislocation; it was produced by the muscular force exerted in lifting a jar. The diagnosis was made, in this case as in one reported by Bahr, with the x-ray. Dislocation of the Ulna or Radius Alone. — Isolated dislocation of the ulna, either backward or forward, is a very rare injury in spite of the frequency of dislocation with marked prominence of the styloid process in fracture of the radius. Backward dislocation is supposed to be produced by forced pronation, the forward variety by forced supina- tion. In both instances the transverse diameter of the lower end of the forearm is shortened. The diagnosis is simple. The author has seen only one instance, and that was an old unreduced dislocation; the mode of origin could not be accurately ascertained. In like manner the author has seen only one instance of isolated habitual dislocation of the ulna which was not questionable. The function of the hand was compromised so little that operative treatment was refused by the patient, a man of forty years. For this condition Hoffa opened the joint by two lateral incisions and sutured the periosteum with apparent success in 3 instances. The statement of Goyrand, that this dislocation is frequent in childhood, cannot be corroborated in spite of the relatively large material at our disposal. The author sides rather with Konig's statement that the pain in the wrist sometimes caused by traction upon the hand is quickly relieved by extending and supinating. All the injuries reported as isolated dislocations of the lower end of the radius resolve themselves on critical examination into fractures of the radius. Dislocation of Single Bones of the Wrist. — Dislocation of single bones of the wrist lays claim to greater practical importance than is apparently attributed to it in the earlier compilations of Tillmanns and Bardenheuer. The x-ray has rapidly increased the figures, and in all cities where many injuries of the extremities are determined by the .r-rav these findings are reported. The importance of the lesion lies in the fact that the resulting functional loss is apt to be pronounced; the reduction may be very difficult, possibly not attempted on account of a wrong diagnosis and under circumstances may require resection. On superficial examination it is diagnosticated as sprain, contusion, or frac- ture of the radius, but can hardly be overlooked by careful palpation, especially under control of the x-ray. Surgeons are indebted to Eigenbrodt for a recent elaboration of the existing statistics in connection with his own observations. From this 304 INJURIES OF THE WRIST AND HAND. review it would seem that the predisposition of the os magnum, as em- phasized on various sides, does not correspond with the facts. Complete isolated dislocation of this bone has not been reported up to the present time. On the other hand, spontaneous subluxation of the head of the os magnum alone or with the upper part of the unciform has occurred back- ward if the ligaments were relaxed (according to Bardenheuer,in weavers; according to Roser and Konig, in women). Eigenbrodt states that iso- lated dislocation of the trapezium or trapezoid has never been reported, or at best only inaccurately. In the cases described as dislocation of the pisiform the bone was fractured by the traction of the flexor carpi ulnaris. Likewise in the few instances of dislocation of the unciform there was never merely a dislocation, but always simultaneous injury of other bones (metacarpals), the fracture of which latter permitted the dislocation. Only scattered and mostly old reports are extant of dislocation of the scaphoid or portions of the same. It is different with regard to the dislocation of the lunar; it may claim the significance of a typical injury. By forcible hyperextension of the hand the lunar and scaphoid are pressed against the metacarpals, and after the flexor ligaments have been torn both bones or one, usually the lunar, are forced out by the pressure of the os magnum. The pressure of the dislocated bone sometimes causes paralysis of the median or ulnar nerve. Treatment. — For all the above dislocations reduction should be attempted by maximal extension for the forward variety, extreme flexion for the backward variety, followed by pressure upon the bone and gradual return of the wrist to its normal position. Operation is resorted to more frequently at the present time than formerly if reduction is impossible, and, if necessary, the resection of single bones. Often the injury was only one of many produced by falling from a height, and the patients died before any plan of treatment could be considered. It should be mentioned that very satisfactory results are sometimes obtain- able by simple immobilization of the wrist and subsequent exercises, as in a case of Eigenbrodt's in which there was complete return of function in two and a half years without reduction or operation. COMPLICATED INJURIES ABOUT THE WRIST. Complicated injuries of the wrist are chiefly the result of machinery accidents, shot- wounds, run-over accidents, penetrating and perforating wounds from within similar to those occurring more frequently in the ankle-joint. The hand may be caught in belting, be severely crushed, caught in combiner- or toothed-wheels, or between rollers; extensive laceration or avulsion of the soft parts may be complicated by opening of the joint, by one or more fractures of the bones; cutting instruments may sever the hand partially or completely, the cut being clean or jagged. The results of conservative treatment are often surprisingly successful in injuries of this sort, the later aspect of the wound giv- ing no clue to the injury. If sepsis occurs, there may be severe func- COMPLICATED I S.I CRIES MioCT THE WHIST. 305 tional loss, ankylosis, contractures, and disturbances of innervation and circulation. The hemorrhage is often comparatively slight in all of these injuries: the vessels are torn, twisted, and closed by the injury. This occlusion may be deceptive, and be followed by severe hemorrhage if the parts are moved, as in transportation. The author has repeatedly seen instances where portions of the radial or ulnar artery, several inches in length, were torn out of the adjacent tissues, pulsating in their entire length, hut closed spontaneously by the torsion. Such injuries were often accompanied by evulsion of the muscles, splinter-fractures of the carpal and metacarpal hones, or complete or incomplete dislocation of the latter. The vessels are never difficult to find at the wrist, and with proper attention will rarely be overlooked. Injury of the radial and ulnar arteries jeopardizes the circulation of the entire hand, but is not an indication per se for amputation. The author has seen the collateral circulation so established by elevation, application of warmth, and omission of all compressing bandages or splints that the hand was saved. If the part is crushed throughout its circumference, there is often no prospect of its preservation. Shot- wounds may be equally unfavorable if the discharge into the hand was at close range, for then the explosive action of the gases damages the circulation more than the circumscribed action of the projectile. The course of compound injuries of the wrist depends essentially upon the extent of the accompanying infection. Suppuration extending throughout the entire joint was and is feared at the present time as much as infection of the ankle-joint. The infection spreading along the damaged tendon-sheaths may endanger the limb or life itself. Treatment. — The treatment should therefore insure drainage, as some discharge is always to be expected. The injured hand should be cleaned and sterilized as soon as possible after the injury; this is often a difficult task. After scrubbing the skin well with soap and warm water the interdijrital folds and the nails are carefullv cleaned. The skin is further cleaned with ether, turpentine, or tincture of green soap; the entire process frequently requires half an hour; the cleansing of the wound follows. The circulation and innervation are first tested; all displacements are then reduced, necrotic tissues excised, the tendons and nerves sutured, and by retention sutures the tissues restored as far as possible to their normal relation. The wound should be left open wherever it is desirable to keep the parts under inspection or where discharge may be expected from necrosed tissue. The cavity may be packed loosely with sterile gauze or drainage-tubes inserted. The wound is then best covered with a dry aseptic dressing, the limb immobilized upon a hand-board, or pasteboard, or light plaster splint, and suspended for several days by v. Volkmann's method. If infection occurs, it should be treated according to the directions already given: in the event of phlegmonous inflammation the wounds are enlarged and drainage obtained wherever retention is imminent. Temperature and local pain Vol. III.— 20 306 INJURIES OF THE WRIST AND HAND. are the best indications for the nature of the treatment. If the course is uninterrupted, the author leaves the first dressing undisturbed for from six to eight days, changing it earlier only if there is throbbing and tense pain in the wound with an afternoon temperature above 101° to 102.5° F. The same rules apply equally to shot-wounds. Resection will be necessary primarily if the bones are badly damaged, and secondarily for suppuration with insufficient drainage. The limits of conservative treatment should be made as wide as possible, but the mechanical possibility should not be overstepped: suppuration in the joint will always demand the sacrifice of one or more carpal bones to insure speedy and certain recovery. General rules cannot be given; experience and objective analysis will determine the mode of procedure. Removal of the articular ends of the radius and ulna should be avoided if possible. (See chapter on Resections.) Ankylosis, more or less firm, is the usual result of every protracted suppuration in the wrist. The prognosis is generally doubtful as to function on account of the involve- ment of the tendons and tendon-sheaths; not only stiffness in the joint, but also severe limitation of the finger movements usually follow the local suppuration ; the earning-efficiency of the patient is often perma- nently compromised. FRACTURE OF THE METACARPALS AND PHALANGES. Fracture of the Metacarpals.— v. Brans, among 553 fractures of the bones of the hand, gives 70 as involving the metacarpals; 9 in the second, 23 in the third, 22 in the fourth, 10 in the fifth, and the remaining G in the first and sixth decades of life. According to Malgaigne, women are rarely affected by this injury (1 in 16). The author has seen only one female patient in the entire material of his polyclinic. Formerly regarded as a relatively rare injury, the number of cases has increased considerably since the use of the .r-ray. There is no demonstrable predisposition of any single bone. Certainly the first metacarpal does not take the place assigned to it by Malgaigne. The fracture may occur in various ways: most frequently the cause is a blow (machinery), shot, or a fall upon the dorsum of the hand; the direction of the force is thus more or less perpendicular to the long axis of the bone and produces an angular deformity toward the volar surface. Less commonly it is a blow upon the metacarpophalangeal joint, due to a fall or collision with a solid body, acting in the direction of the axis of the shaft; this presupposes that the hand is clenched. (Hamilton, several own observations.) Dupuytren reports a rare frac- ture in wrestlers, the metacarpals being bent backward when the hands are interlocked in the effort to throw the opponent. Whereas by direct violence the fracture can occur at any point, the break resulting from indirect violence is almost always oblique or a long fissure-fracture in the middle of the shaft. Infraction of the neck and crushing of the head PLATE IX FIG. 1. Fracture of Carpal Scaphoid. (Stimson. FIG. 2. Fracture of the Third, Fourth, and Fifth Basal Phalanges. (Solley.) FRACTURE OF THE METACARPALS AND PHALANGES. 307 Fig. 205. are not rare, and from. the history are caused by violence in the axis of the bone. Traumatic separation of the epiphysis <>f the metacarpals, designated by Bardenheuer as a frequent injury in childhood, the author has seen in only a few instances; likewise fracture of the base of the first meta- carpal (stave of thumb, Bennet's fracture), recently reported by Prichard and Beatson, is easily mistaken for sprain of the thumb and does not belong among the "frequent" injuries. The displacement is often hardly recognizable on account of the position of the bone between the small muscles of the hand; but it may be so pronounced that the head projects proximally J inch beyond the adjacent metacarpals. The .r-ray always shows the fracture-line if the rays penetrate in the proper direction, although deception is possible. The fracture-line is usually proximal-dorsal to distal-volar; the lateral displacement is slight, and if the fracture-line is long and the illumina- tion is dorsoventral, the line may not be seen. In the same manner in transverse (radio-ulnar) illumination the fracture-line may be concealed by the adjacent metacarpals; accurate information is then obtained by semipronating the hand. The distal fragment, especially the head, usually projects somewhat into the palm, the projecting proximal edge of the distal fragment being recognizable on the dorsum, together with pain on pressure or crepitus. If there is much extravasation — which is uncom- mon — the signs on palpation may be less pronounced than the localized point of tenderness. False motion can generally be elicited by proper manipulation of the fragments. Exceptionally the fixed point of tenderness will be the only symptom except the swelling produced by the ex- travasation. If the head is broken off or crushed, one usually finds it or the pieces project- ing into the palm, the proximal part of the shaft projecting on the dorsum. The first phalanx of the finger sinks into the palm with the head, especially in the case of the fifth metacarpal, and may resemble volar dislocation of the finger. Crepitus is always present and the test of the joint-function' confirms the diagnosis. Treatment. — The symptoms may be so slight that the fracture heals satisfactorily without special treatment. In other cases an underestimation of the injury may result in protracted disability of the affected finger or even the entire hand. It is therefore advisable, if dis- placement is evident, to reduce it by traction upon the finger and pressure Coaptation splints for fracture of the metacarpals. (C. Beck.) 308 INJURIES OF THE WRIST AND HAND. upon the fragment, and to immobilize in a splint. For this purpose a dorsal and a volar splint have been applied (Albert, Konig) and the pressure upon the dorsum increased by appropriate padding (Malgaigne). The method of Carl Beck is illustrated in Fig. 205. Bardenheuer employed continuous traction, and was pleased with the results. If the displacement is still pronounced after attempted reduction by forcible traction, the author applies a splint corresponding to a double inclined plane, the finger being fastened with adhesive plaster to the shorter incline and padding placed under the head of the metacarpal if necessary. Anyone can convince himself that the fracture is not to be regarded indifferently from the prognostic point of view by follow- ing it to the time of complete functional return. Although the splint may be removed at the tenth to the fourteenth day, the full earning- efficiency may not be restored till the third or fourth week even in favor- able cases. Many require a longer period, and regain the full power and full use of the hand and fingers and tendons without pain only by regular massage and passive and active motion. Even the lack of strength and dull, weakening pain may impair the full earning-efficiency for months. Comminution, although rare, can produce aseptic necrosis of small fragments in the metacarpal as in the metatarsus; the incom- plete recovery troubles the patient and justifies secondary removal of the splinters. Fracture of the Phalanges. — According to v. Brims, fracture of the phalanges constitutes 5 per cent, of all fractures; directly, it is rarely subcutaneous, but more frequently compound. The fracture is usually indirect, but is not common on account of the mobility and short- ness of the bone. Separation of the epiphysis is rare. In subcu- taneous fracture the traction of the flexors produces angular deformity with the point of the angle toward the dorsum, and shortening. The fracture-line usually corresponds to that of the metacarpal, proximal- dorsal to distal-volar. Exceptionally there may be lateral displacement of the distal fragment, or dorsal displacement from predominating traction of the extensors. Diagnosis. — The diagnosis is simple. Crepitus is constant. Partial or complete separation of the epiphysis or partial fracture of the latter may simulate dislocation. The phalanx is then curved somewhat toward the palm, as, for example, in fracture of the dorsal part of the epiphysis; the phalanx is freely movable; there may be crepitus in the joint. Longi- tudinal fracture is rare and is recognizable later by the involvement of the joint. (Kronlein.) Forcible flexion may cause a piece of the base of the first phalanx to be torn off by the traction of the extensor tendon. (Busch.) The author has seen two such cases; the separated fragment of the end-phalanx lies over the second interphalangeal joint, or may even be drawn up into the palm; flexion of the end-phalanx is lost; there is pain in the joint on passive motion. Treatment. — As there is not infrequently a tendency toward rotation at the site of fracture, in addition to the tendency to displacement, the rotation should be prevented by a spiral of adhesive plaster, over which DISLOCATION OF METACARPUS AND PHALANGES. 309 a light volar plaster splint is applied with the fingers slightly flexed, the splint extending from the wrist to the finger-tips. Although such extensive immobilization may seem a hit precise, it is advisable for people of the laboring-class. DISLOCATION OF THE METACARPUS AND OF THE PHALANGES. Dislocation of the Carpometacarpal Joint.— The earpometacarpal dislocation is one of the rarest of dislocations. Bnrk has recently col- lected 24 instances of dislocation of the metacarpals, with the exception of the thumb, and added a case seen in v. Brims' clinic. Dislocation of the entire metacarpus is very rare, as the ligaments between the carpals and metacarpals are very firm. Among Burk's cases there were 4 volar, 3 dorsal, and 1 lateral dislocation, most of the metacarpals being displaced dorsally (second, third, and fourth), only one (the fifth) toward the palm. The cause was always severe direct or indirect violence; in the latter case by hyperflexion, hyperextension, or lateral compres- sion of the metacarpus. The characteristic symptoms are shortening of the hand and fingers, a transverse bony projection upon the dorsum or in the palm, and limited flexion of the fingers. Dislocation of one or more metacarpals is usually dorsal (14 dorsal, 2 volar, Bnrk). Dorsal dislocation is usually complete; subluxation is the rule in the volar form. Isolated dislocation of the first metacarpal is most common; it is usually incomplete, but may be volar, dorsal, complete, incomplete, or habitual. Incomplete dorsal dislocation of the first metacarpal presupposes hyperflexion and adduction. In a number of cases there was apparently simultaneous, backward pressure upon the head. A further cause may be a fall upon the thenar eminence near the outer end of the metacarpal lever-arm, or near the head. The author has seen 3 instances of voluntary subluxation of the first metacarpal backward and somewhat outward ; 2 were in children eleven and thirteen years old, and 1 in a man of twenty-three. In each instance the displace- ment could be produced by flexion and maximal adduction of the meta- carpal; it occurred with a snap and slid back into its proper place against the trapezium on abducting and extending. Dislocation of the Phalanges (except of the Thumb). — Among 19S dislocations Weber reports 20 of the fingers; among 400 dislocations in v. Langenbeck's clinic Kronlein reports 27 of the metacarpophalan- geal joints (7 per cent.). The greater frequency of metacarpophalangeal dislocation compared with carpometacarpal is explained by the greater range of motion in the former joint, and by the fact that in use and during the injury the corresponding finger acts as a whole, the force accordingly being applied through a longer lever-arm. Two strong lateral ligaments on the tight capsule of the joint insure the hinge movement about the transverse (radio-ulnar) axis; during extension they are slightly relaxed, and therefore allow slight lateral dis- placement of the phalanx upon the metacarpal. Limitation of flexion and 310 INJURIES OF THE WRIST AND HAND. Fig. 206. extension depends upon the resistance of the capsule and the reinforcing transverse fibres stretched between the lateral ligaments. These trans- verse fibres form the pulleys over which the tendons are able to carry out the movements of the finger-joints in an angular position, and are therefore essential for the use of the fingers. In the thumb they are reinforced by the sesamoid bones (of which the inner is small and solid, the outer broader and less compact), hence the term ligamenta inter- sesamoidea. The fibres running from the transverse ligaments to the dorsum are weaker in proportion to the lesser demand made upon them. The average normal range of flexion is 90 degrees, of extension 30 degrees; this range, particularly that of extension, is often increased considerably in children, in pianists, saddlers, and mechanics, frequently as the result of a steady occupation. There are many women, and children of both sexes, in whom these bilateral ligaments are so relaxed that the usually limited lateral displacement can be increased passively from one-third to one-half the width of the joint. Habitual or volun- tary subluxation is then not infrequent. Dorsal displacement of the first phalanx upon the metacarpal may be designated as a typical phalangeal dislocation; it is very common in the thumb, and for this reason will be con- sidered separately on account of its practical significance. Interphalangeal dislocation is rare, and is usually dorsal. The cause is almost al- ways hyperextension. (Fig. 206.) Volar dislo- cation is even more rare; Huter questions whether it is caused by maximal flexion. The accompanying illustration (Fig. 206) shows an old unreduced dislocation of the end-phalanx. The position of the finger is characteristic: the affected joint is extended, the proximal joint flexed, and the finger shortened; in a recent case there was an actual shortening of -J- inch; in the old case the middle phalanx was increased al- most h inch in length as the result of the growth caused secondarily by the pressure. This illus- tration is introduced because even at the present time the importance of dislocation of the pha- langes is underestimated or not even considered. Lateral dislocation has also been seen. (Mal- gaigne, Riedinger, own observation.) If part of the lateral ligament remains intact the phalanx may be dislocated and rotated in the direction of the ligament. The author has repeatedly seen such rotation in cases of complete disloca- tion of the joint-surfaces. Fracture of the head of the proximal bone (metacarpal or phalanx) is easily mistaken for dislocation. Treatment. — The rule to reduce in the line in which the violence produced the dislocation applies here; so it is advisable in dorsal dis- location to hyperextend, in the volar form to hyperflex. This is usually Old dislocation of end-phalanx of index finger with secondary elongation of the second pha- lanx from the irritation. PLATE X. Fresh Dorsal Dislocation of the Thumb. (Stimson.) DISLOCATION OF METACARPUS AND PHALANGES. 311 easy and requires no particular appliances. If the dislocated phalanx is simultaneously rotated, it is abducted in the direction of the still intact portion of the ligament. For every dislocation the author recommends immobilization from five to seven days, followed by active motion. Dislocation of the Thumb. — The thumb is more frequently dislocated than any other finger; according to Gurlt, the lesion constitutes 5 per cent, of all dislocations. Complete dislocation is estimated by Malgaigne at 3 per cent. The injury is confined almost exclusively to middle-aged men; single instances in children five to twelve years old have been observed by Malgaigne, Blandin, Bardenheuer, and others. As Bardenheuer says, the diagnostic errors and difficulty of reduction are responsible for the unfortunate reputation of dislocation of the thumb. Mechanism. — The causes discussed previously in reference to disloca- tion of the fingers apply here. Surgeons are indebted to Farabeuf for Fig. 207. Simple complete dislocation of the thumb, outer side. (Farabeuf.) one of the best descriptions of the mechanism of dislocation of the thumb. According to his classification, one may distinguish practically: a) luxatio incompleta, (b) luxatio completa, (c) luxatio complexa. In this classification the position of the sesamoid bones is decisive: in incom- plete dislocation they still lie at the joint-surface of the metacarpal; in the complete form they are displaced backward; in the complex form they are reversed and interposed. In (a) the base the phalanx is still partially in contact with the joint-surface of the metacarpal; in (b) and (c) it is always completely dislocated. A sudden blow received upon the pal- mar surface of the thumb hyperextends the same; the posterior border of the base of the first phalanx presses against the back of the metacarpal, the flexor ligaments are put on the stretch, are torn by the continuation of the force — almost always at their insertion on the metacarpal — so that the greater part of the volar ligaments remain attached to the phalanx and slip backward with it, usually accompanied by the sesamoid bones. :i2 INJURIES OF THE WRIST AND HAND. The head of the metacarpal, forced out through the volar rent, becomes button-holed at its neck in the ring formed by the retracting parts of the capsule. The tightness of this ring is occasionally increased by the simultaneous, stronger contraction of the heads of the flexor brevis. The lateral ligaments are torn partially or completely, the stronger one on the inner side holding out the longest. If the latter is not torn, only the outer sesamoid bone may be displaced backward, whereas the inner or ulnar bone may be forced inward with the tendon of the flexor longus pollicis. If the inner ligament is torn partially or completely, the inner sesamoid bone will lie upon the back of the metacarpal. The fibres of the flexor brevis may be torn, the abductor brevis usually remains intact, the adductor is displaced. At the moment of dislocation the tendon of the flexor longus pollicis usually slips to the inner side of the head of the metacarpal and may be hooked over its neck. (Frank, Ilelferich.) The chief hindrances to reduction result from the position of the structures about the joint: interposed capsule (Pail- loux) with one or both sesamoid bones and the flexor longus pollicis slipped or hooked over the metacarpal. The hyperextension of the phalanx is frequently followed by flexion caused by muscular traction; if the flexion toward the palm is increased by pressure upon the phalanx, the base of the bone tears off the already lacerated ligament; the latter curls up backward, the sesamoid bone rotates and then lies reversed between the base and the metacarpal (luxatio complexa). Fig. 208. Complex dislocation. (Farabeuf.) Symptoms. — From the foregoing the symptoms should be clear. On inspection the chief variations depend upon whether the hyperextension still exists, the thumb being at a right angle to the metacarpal; or whether the subsequent traction of the flexors has brought the dislocated phalanx approximately into a position parallel to the metacarpal. (Fig. 208.) In the former case, aside from the abnormal position of the thumb, the most striking thing is the bulging of a hard rounded body in the palm, the head of the metacarpal, which may be mistaken for the base of the phalanx. If flexion has taken place, besides the head of the metacarpal DISLOCATION OF METACARPUS AND PHALANGES. 313 being felt in the palm, the small articular surface of the phalanx is fell on the dorsum like a small disk, analogous to the articular surface of the head of the radius in complete backward dislocation of the forearm. If the flexion of the phalanx is increased by pressure, its joint-surface can be felt so plainly that it can scarcely he mistaken by the examiner. Comparing the backs of the two thumbs shows the shortening of the metacarpal axis, \ to ■', inch. Active and passive extension is impossible. The second phalanx is almost always flexed upon the extended first phalanx. (Fig. 207.) Treatment. — Reduction is usually easy if the general rule is followed to reduce a dislocation in the same way in which it is produced, namely, to begin with hyperextension (maximal dorsal flexion). Force is not necessary: hyperextension of the thumb, pressure from behind against the base of the first phalanx, then pushing it forward with simultaneous flexion of the thumb. Sometimes, particularly if the internal lateral ligament is intact and the phalanx is adducted, it is well to combine gentle rotation about the intact ligament as a centre with the above-mentioned manipulation. The unequally wide gaping of the joint-struetures from each other may allow the parts to be interposed on the outer side, the inner side remaining free. The most important of the hindrances to reduction mentioned is the interposition of +he capsule, sometimes with one or both sesamoid bones. Whereas in incomplete dislocation the author attempts to push the sesamoid bones and the base of the phalanx downward and forward, if there is any interposition it is well to begin by pulling forcibly upon the thumb in the direction of the dislocation; the interposed parts are usually freed in this manner. By increasing this traction the hyper- extension is increased to a right angle or further and, allowing the dorsal edge of the base of the phalanx to rest against the dorsum of the metacarpal, the anterior border of the phalanx is levered up so that the phalanx, ligament, and sesamoid bones may be pushed forward; the joint-surface of the phalanx is then pushed forcibly and gradually forward upon the joint-surface of the metacarpal while flexing. The metacarpal must meanwhile be held firmly, the end-phalanx slightly flexed to relax the flexor longus pollicis. The author desires to warn against the use of all sharp reduction instruments; Liier's instrument is often described and illustrated. The ideal instrument is the hand of the operating surgeon guided by the knowledge of the mechanism of injury. Assuming that the hindrance is caused by the tendon of the flexor longus pollicis winding around the neck of the metacarpal on its inner, or ulnar, side (Ballingall, Dittel, Lauenstein, and Helferich), the thumb may be adducted slightly and rotated to the right (clock- wise) . This grip aids every difficult reduction, as the tendon, without being itself the actual hindrance, may by its tension press the torn anterior part of the capsule between the surfaces of the joint. Relaxing the tension of the tendon makes the interposed parts of the capsule movable or yielding. The tense lateral ligaments also, if partially intact, may hold the base of the phalanx behind the 314 INJURIES OF THE WRIST AND HAND. head of the metacarpal; they may be gradually relaxed by increasing the dislocation. If reduction is not possible, the patient should be anaesthetized; if still unsuccessful, in spite of thorough trial of the above procedure, nothing remains but operation. The author would recommend imme- diate operative reduction in all cases resisting the above technic. The author has never had any experience with subcutaneous tenotomy of one or more tendons and division of all tense parts. This procedure is no longer in accord with the demands of modern surgery; namely, fullest possible inspection, least possible hemorrhage, and asepsis. In the given case a radial lateral-incision is most advisable: 1. Because the future scar does not interfere with the use of the hand. 2. Because the axis of the metacarpal is exposed easily without hemorrhage or division of the muscles. 3. Because the most frequent unsurmountable hindrance is the outer sesamoid bone and this is thus exposed. The soft parts are drawn well apart with sharp retractors, the ligaments loosened, dis- placed portions of ligaments excised, and the sesamoid bone removed. By slightly adducting the thumb the surgeon can obtain a good view of all the parts, can remove all hindrances, and after suturing the capsule with two or three sutures of fine silk, may completely close the wound. The splint should' include the first and end-phalanges of the thumb slightly flexed. Motion should not be begun before the fourteenth day. In old cases (after three to six months) resection of the head of the metacarpal may be necessary. Shortening of the metacarpophalangeal axis is then desirable, as otherwise it is not possible to maintain the cor- rection with certainty. The function is incomparably better than before the operation, but rarely restores the normal excursion of flexion and extension essential for a good grip. Painful sensations during motion may last for a long while. Volar dislocation of the first phalanx of the thumb is very rare, and is easily explained by the infrequency of the line of force required, namely, maximal flexion. (Lenoir, O. Weber, Hamilton.) Force pro- ducing abduction or adduction may also be concerned (Meschede) ; the thumb is usually found at the same time in a position of radial or ulnar abduction. The extensor tendons can presumably be interposed. Bessel- Hagen has seen pure, radial lateral dislocation and explained its origin. y WOUNDS OF THE HAND AND FINGERS. Whereas the judgment of simple wounds of the hand and fingers makes little claim upon the surgeon, the complicated wounds, especially those due to the highly developed, modern, mechanical industries, make large demands upon his judgment and technical ability. Incised and Stab-wounds. — Owing to the favorable conditions of the circulation of the hand and fingers, these wounds recover under simple treatment; cleansing the wound area, freshening the edges if WOUNDS OF THE HAM) AND FINGEBH. 315 soiling or infection is probable, and a few sutures, sterile or bichloride dressing, and small pasteboard splints, are sufficient. Recovery ma) be uneventful even if the wound involves a hone or a joint, or part of a finger has been cut off. From the author's experience and that of others there are reasons for hoping that completely severed portions of fingers, if sutured in place and bandaged lightly within a tew hours after the injury, may grow on again. Division of the tenden is often overlooked in small incised wounds. The earlier it is sutured, granting that then is no infection, the more favorable will be the result. (See Technic of Suture of the Tendons, page 282.) Gunshot- wounds. — The shot-wounds resulting so often from acci- dental discharge of a revolver, rifle, or shotgun are usually simple with reference to treatment: the bullet or shot is removed without difficulty if accessible. The .r-ray gives accurate topographical information, an im- portant consideration if there are several bodies. An extensive discharge of fine shot lies palpably beneath the skin, and its removal is apparently possible through a superficial incision; lateral illumination with the it-ray shows the error and warns of the necessary care with reference to the deep-seated shot. Bullets often heal in without causing disturb- ance. Shot-wounds of the palm, which are apt to carry infectious material with them, more often cause infection; the author treats them on general principles. Free incision is indicated primarily only for marked hemor- rhage or comminution of the bone. Puncture- wounds. — Puncture-wounds give a widely varying prog- nosis, and it is often difficult to decide as to their treatment. Even the apparently harmless sort on the back of the finger can easily penetrate into the joint; those on the palmar surface not infrequently introduce infectious material into one of the tendon-sheaths with all the conse- quences of infection. Puncture-wounds in the palm caused by splinters of glass or cutting metal instruments are interesting on account of the profuse hemorrhage. The superficial palmar arch is easily injured and hemorrhage from the deep arch is not rare. In all these cases it is the rule to obtain free inspection of the source of hemorrhage by enlarging the wound and separating the edges with sharp retractors; then to ligate. Where the hemorrhage is profuse, if the Esmarch is applied, on releasing it the injured vessel is quickly found. Here and there one finds the application of styptics recommended, especially chloride of iron or Penghawar Djambi. Lack of assistance and restlessness of the patient may excuse their use, but the uncertainty of their action may lead to greater difficulty in checking the hemorrhage, for the chloride of iron, in coagulating the albumin, obscures the anatomical details, and if secondary bleeding demands interference, the field is less clear than before. In such cases the author would recommend firm application of an aseptic dressing on the bleeding spot and suspension of the limb, as advised by v. Volkmann. The arm should be placed in a well-padded wood, tin, or pasteboard splint, the patient made to lie down, and the arm well elevated by means of a suspension apparatus (v. Volkmann's), or an improvised upright with a loop or pulley, rope, nail in the wall, etc. 316 INJURIES OF THE WRIST AND HAND. Foreign Bodies. — Small foreign bodies can almost always be palpated with the end of a probe; larger bodies are sought through the path of entrance. In the former case, however, with insufficient anaesthesia, larger or smaller exploratory incisions are frequently made about the wound without finding the foreign body. The rule, to make every exploration of foreign bodies bloodless and with local anaesthesia, rarely fails if carefully followed. The etiology of foreign bodies is extensive. Needles, especially portions of the same, wood, metal, and splinters of glass form the largest contingent. The frequent "wandering" due to the manifold movements of the hand and the contrast between the cicatrix left behind at the site of entrance and the size of the foreign body are often surprising. In treating small wounds of the hand and fingers, local anaesthesia has proved of immense value. For wounds of the fingers the author uses Oberst's method exclusively with a simple 4 per cent, cocaine solution. Schleieh's injection method is valuable in operations on the hand and wrist; also circular anaesthesia as recommended by Manz, Berndt, and Holscher. Complicated Injuries. — The most complicated injuries of the hand occur among the operators of machinery in the great industries. Sudden contusion is usually combined with the effects of traction and tearing. The hand is caught between toothed rollers or between driving-wheels or cog-wheels; is crushed or frayed; or there is extensive evulsion of tendons and muscles; or the structures may be sawed smoothly through by a circular saw, etc. The multiplicity of wounds of the soft parts, tendons, joints, or bones, is often such that the peculiar character of the case may make it difficult on first inspection to form an opinion as to the prognosis. It is well before anaesthetizing the patient to obtain permis- sion to do any curtailing operation that may be necessary. It is these severe complicated wounds of the hand that represent an extremely profitable domain of conservative surgery. The superficial position and easy accessibility, even of the bones, reward one greatly for proceeding carefully. Guided by the experience that it is impossible at times to determine how far contusion will be followed by necrosis, the surgeon will do better, when uncertain, to let nature determine the separation of living tissue from the dead: the author saves everything that can be saved, and never cuts away anything merely for appear- ance' sake. In general it is much better to leave too much than too little. Not infrequently the first dressing may be left on six, eight, or ten days, and at the end of that time one will often have the satisfaction of finding a clean wound. The drains leading down to the bone, joint, or tendon suture may require changing on the third day, and need not be replaced if the wound is clean. If there is fever or severe pain in the wound, the dressing should be changed earlier. The appearance of in- fection and corresponding inflammatory changes demand the applica- tion of all the measures described under acute infections; loosening the sutures and preventing retention by appropriate drainage. Formerly, and WOUNDS OF THE HAND AND FINGERS. >s\l in many clinics, continuous irrigation or the continuous hand-bath were used extensively for beginning infection. Their value is incontestable, but at the present time they are generally abandoned and their equiva- lent found in wet dressings. The bath is indicated, however, if the infection advances without recognizable demarcation or abscess forma- tion. If the treatment has not been such as was described for the "toilet" of the wound in recent injuries, but rather has gone too far in "leaving the cleansing of the wound to nature," or, what is a greater mistake, the wound has been closed tightly where there was a possibility of infection, so that the glowing coals are deposited in the depths, severe infection is liable to follow. The author therefore summarizes the therapeutic Facit of these com- plicated wounds of the hand in the words: First, to determine the anatomy of the wound, tendons, joints, nerves, and, under all circum- stances, the vessels; then to proceed carefully to conserve the individual parts and thereby the function; and finally to leave the wound open to the proper extent on account of the danger of infection. By strictly observing these principles one will not only be agreeably surprised in the treatment of wounds of the hand, but confer many a blessing upon the welfare of the patient as well. Serious Results of Wounds and the Possibility of Their Prevention. This subject has acquired an unusual practical significance in conse- quence of accident legislation. It deals with the important question of the attending surgeon's statement as to the prognosis of recent injuries and the question of estimating in advance the loss in earning-efficiency to be expected. It exposes the surgeon to manifold subsequent criticism in the discussion of what has been done and might have been done. Finally, it arms the patient, under circumstances, with a just grievance as well as giving occasion for conscious or unconscious exaggeration of the disability produced by the injury, and, by reason of the space taken up by wounds of the hand in the entire question of accidents, its precise and fair judgment becomes a social factor of the greatest importance. The author will take pains to place the purely surgically technical in the foreground, still he would be ignoring the practical character of the task before him if in the following lines he did not allow the aid in the direction of the above-mentioned judicial considerations to be recog- nizable. Changes in the Skin. — Among the changes in the skin following injuries, trophic and circulatory disturbances are important. The condition of the finger which Ledderhose terms "Glanzhaut" has been seen following protracted immobilization, the application of con- stricting dressings, or as the result of flaps too short for the stump. Glossy skin is characterized by a peculiar smoothness, glossiness, cold- ness, and purple hue of the skin; the finger is large and swollen, or the skin is lean and tense like parchment; in fact, it reminds one of the sclero- dactylia of scleroderma, or the "glossy skin" referred tc contusion of 318 INJURIES OF THE WRIST AND HAND. the nerve and described by Paget. The condition may be hypertrophic or atrophic. The former represents to a certain extent the first stage, the latter the second stage in the formation of glossy finger. The con- dition may persist through life. Symptoms. — The symptoms are most pronounced toward the tip of the finger. On incising (as, for example, in reamputation) the skin shows a striking absence of arterial bleeding. Microscopically the cutaneous arteries show changes and growth in the iiitima, the subcu- taneous fat is absent and replaced by connective tissue. With this con- dition, even moderate cooling of the skin produces marked circulatory changes due to the spastic contraction of the vessels; cyanosis, distinct feeling of coldness, and irritation of the nerve follow. The nervous dis- turbances lead more and more to the picture of a local neurasthenia or hysteria, or gradually reveal a general traumatic neurasthenia. Glossy finger may thus be a very serious restdt of injury. The condition can disappear partially or completely in a varying length of time, even within a few months. The nervous changes, hyper- esthesia and its reaction upon the function, once established may persist for a long time, even in patients in whom there can be no question of wilful exaggeration of the trouble. There are even cases in which reamputation is the only means of bringing about recovery. Treatment. — The treatment is accordingly extremely important. The author agrees fullv with Ledderhose in regarding faulty, overconserva- tive technic in the amputation as the chief cause of the condition. The main things to be avoided in the after-treatment of wounds of the fingers are cicatricial contraction and adhesion of scant flaps of the soft parts to the bone, protracted immobilization in splints, and the compression of overtight bandages. Post-traumatic Neuritis of the Hand and Fingers.— In addition to the changes in the vessels and adipose tissue causing glossy finger, the wandering neuritis following wounds of the hand and fingers is interest- ing. External violence is an important cause in diseases of the peripheral nerves; the disease is inclined to follow the injury immediately in as far as the process of degeneration advances toward the periphery. The centripetal disturbances in the nerve have also been investigated, Krehl particularly having won the distinction of having carefully studied and published their symptomatology. Progressive neuritis follows particu- larly the injuries accompanied by inflammatory changes. The char- acteristic and practically important point in the disease lies in the fact that a "process spreading atypically produces the symptoms of a disease, whose course is entirely incalculable from the outset and is usually extremely chronic." The nervous symptoms sometimes appear rather late: if there are paresthesias in the area involved, there is dimin- ished pressure, pain, and temperature sense. Sensory disturbances may be absent. Motor disturbances are constant: atrophy of the muscles, reaction of degeneration, frequently in the small muscles of the hand, the long muscles of the forearm meanwhile merely showing paresis. The treatment and prognosis are those of the primary chronic neuritis. WOUNDS OF THE HASH AND FINOEES 319 Cicatricial Contraction. The severity of the contraction depends upon the depth and extenl of the destruction and defect caused by the trauma. The contractures following burns were particularly dreaded at an earlier period. The contracture is due either to shrinkage of the skin alone or further to adhesions with the underlying parts, the tendons or bones; or it is the result of changes in the tendons, of ankylosis of the joint, or of lesions in the nerves of the antagonistic muscles. The examination directed toward the above disparity in the etiology will always give a clear idea of what is possible by operation. (For details, see section on Contractures.) Very high-grade myogenic contractures may follow suppurative myositis or the so-called ischsemic paralysis. Suppuration in the muscles of the forearm following phlegmon in the fingers or hand, to be discussed later, may cause destruction of the con- tractile muscular fibres, followed by cicatricial shortening of the muscles. Surgeons are indebted to v. Volkmann for accurate knowledge of ischemic paralysis, the serious consequences of which are seen especially in the upper extremity from obstruction of the circulation, particularly by tight dressings. In a few hours the patient complains of severe pain, the parts not included in the dressing being swollen, the fingers forced into a flexed position. If the dressing is removed, the tense infiltration of the muscles may disappear without damage and the momentary dis- ability rapidly yield to movements. If the circulatory disturbance con- tinues and the dressing remains twenty-eight or forty-eight hours, in spite of the patient's vehement expression of pain, destruction of the contractile substance of the muscles and nuclear degeneration follow; at the same time there is an enormous infiltration of leucocytes. These changes do not involve the muscle uniformly, but in all places where they have been pronounced, severe muscular atrophy follows with con- tractures of the hand and fingers. If the circulatory disturbance has not existed too long, the usefulness of the paralyzed muscle may be almost completely restored by movements, massage, and electricity, if persevered in; in the muscles greatly involved, the shortening and contracture persists. The Joints. — Changes in the ligaments, thickening and shrinkage following exudates, adhesions, and circulatory disturbances of various kinds, often prevent the use of the joint for a long time. In the case of wounds of the hand and fingers it should therefore be made a rule to insure the freest possible play of the joint by omitting it in the dressing, and if there is inflammatory or traumatic congestion, to begin massage and motion early. If it must be included in the dressing in a splint, active or passive motion should be carried out at every change of the latter. The degenerative changes in the joint itself are serious; they may be in the form of loosening of the structures of the joint after traumatic effusion, or long-standing inflammatory exudation in or about the joint; or immobilization or contracture may have kept parts of the surfaces of the cartilages out of contact for a long time. Actual deforming processes thus ensue in the articular surfaces. The disused cartilage atrophies 320 INJURIES OF THE WRIST AXD HAND. partially and is replaced by connective tissue. Whereas the first-men- tioned changes cao usually he controlled by careful treatment, the latter naturally presents greater difficulty and may cause lasting functional loss. It is therefore advisable in every case of protracted immobilization to insure the greatest possible range of motion for the joint. Post-traumatic Ossifying Periostitis.— The significance of this lesion for the function of the tendons and the joint should not be underesti- mated, yet the traumatic factor is not infrequently overlooked in the history. Following a blow from a hammer or a contusion of any sort, or a severe strain, slight sensitiveness persists in the bone, perhaps localized near the sprained joint, but not infrequently extending over the entire metacarpal or phalanx. At this stage the patient often gives in- definite information: slight functional impairment of flexion and exten- sion, easily regarded as exaggeration or simulation, ought to indicate the necessity of a careful comparative examination. Likewise the .r-ray does not show any alteration in the thickness of the bone. Later, the thickening of the affected portion, or the circular thickening of the entire bone, becomes more and more plain, and in a few weeks the product of the periostitic ossification is evident. The otherwise healthy appearance of the patient, the occurrence of the affection in middle life, and the exclusion of specific disease in the history, soon establish the diagnosis. Active and passive motion, massage, and baths are to be prescribed; immobilization would be an error. Sudeck has called atten- tion to a "reflex" atrophy of the bone, following aseptic inflammations, and recognizable with the aj-ray. 'See Chronic Affections of the Bones.) CHAPTER XX. DISEASES OF THE WRIST AND HAND. ACUTE INFLAMMATORY PROCESSES IN THE HAND AND FINGERS. Acute Inflammatory and Phlegmonous Processes Starting as Panaritia. Deep Phlegmon of the Palm. Phlegmon of the Forearm. The acute inflammations of the soft parts of the hand are so much more important than those of the foot with reference to temporary or permanent limitation of the usefulness, and thereby usually the earning- efficiency, of the hand, that the practical demands are well met by not making the description too short. In the following the author will consider together all the inflammatory processes classified as "panaritial." One may differ in his opinion as to whether this corresponds to the present condition of our knowledge. Nevertheless it takes well into account the practical and didactic needs. The anatomical differences, prognostic-ally so important, and the corre- sponding therapeutic indications developing directly from a picture of infection that is clinically often apparently very uniform, appear to the author more profitable than any a priori anatomical definition. This analysis appears to him all the more urgent since even at the present time Konig's words still apply, namely, that "there are hardly any of the diseases of daily occurrence which, by reason of neglect, so fre- quently produce serious result for the patients, and in reference to which so many therapeutic transgressions occur, as panaritia." How much can be preserved by carefulness and skill, how much is sacrificed with reference to work and existence by neglect! Every panaritium is an expression of traumatic inflammation, whether the surgeon is able to demonstrate grossly the trauma and the consequent lesion in the tissues or not. A wound in the skin, often microscopical, serves as the portal of invasion for the exciters of inflammation. Today surgeons no longer discuss the question of specific injuries. Koch's culture experiments showed that in every case one or more of the varieties which are designated inexactly as pyogenic bacteria, were found in the inflammatory exudate: streptococci, staphylococci; exceptionally bacilli, proteus, coli communis. Very frequently the patients remember a small puncture-wound or laceration received within a few days, or the traces of such are found. Often occupational injuries are responsible, as in the case of carpenters, locksmiths, cooks, also surgeons; anatomists and surgeons constitute a fair contingent. Occasionally, on incising, a small Vol. III.— 21 ( 321 ) 322 DISEASES OF THE WRIST AND HAND. foreign body is found in the pus: splinters of metal or wood, pieces of fish-bone, particles of bone. The disease is common in youth and middle age. The right hand is more frequently affected, in proportion to its greater use. Cutaneous Panaritium. — The clinical aspect of cutaneous panaritium is determined . by the anatomical peculiarities of the skin of the hand and fingers. Whereas elsewhere on the upper extremity the subcutaneous connective-tissue fibres run almost parallel to the long axis and join skin and fascia at a sharp angle — as applies also in general to the back of the fingers — the connective tissue on the flexor surface is thick and tense, the fibres running in a short course almost perpendicularly inward from the papillary bodies. (Hiiter.) The mobility of the volar skin upon its substratum is therefore very limited, so that it yields only slightly from within outward (as in exudation). As the connective-tissue spaces permit of only slight lateral distention, high intracutaneous pressure is thus rapidly established. From this it can be understood why spontaneous perforation takes place at the sides of the fingers, where the skin is thinner and more movable; further, why this localized increased pressure affects the adjacent structures — tendon-sheaths, periosteum, and joint — at an early period. The first law of treatment is immediately deducible: incision as early as possible. Therefore, although cutaneous panaritium insures clinically the prog- nostic advantage of local limitation and slow advancement, this mechan- ical limitation has the evil effect of producing very severe pain, necrosis of the tissues from the marked impairment of the circulation due to the increased pressure, and relatively high fever. The panaritial process in many respects resembles furuncular inflammation, which latter at the outset meets with equally firm opposition. Necrosis is rarely absent in panaritial inflammation, as mentioned. The effects upon the circulation in the unyielding volar tissues, in addition to favoring necrosis, is manifested by a second symptom of prac- tical importance: the early appearance of redness and swelling on the dorsum, where, as has been seen, the connective tissue is much more yielding and distensible. It is always surprising to the beginner, when the oedema is greatest on the dorsum, to finally discover the source of infection and chief focus of inflammation on the flexor side; and this is where it usually lies. Incisions at wrong spots are often avenged by the increasing opposition of the patient against further possibly futile attempts, with the result that a timely incision at the proper place is omitted. This dorsal swelling can lead to greater error in panaritium of the palm than in that of the finger. If the inflammation has advanced beneath the palmar aponeurosis — which always happens if the process spreads — the dorsal swelling is more marked than the symptoms of inflammation in the palm; for the veins emptying into the large branches of the palmar arch and passing through the interosseous spaces from the dorsum to the palm, are then under increasing pressure. At an early period, therefore, marked cyanotic oedema is found on the dorsum, whereas inflammation beneath the thick callus of the palm is hardly A CUTE IXFLAMMATOR Y PROt ESSES IX HAND AM) FINGERS. 323 suspected. The primary focus of infection in the palm cannot be over- looked if the tenderness is tested carefully. 1 >rainage of the tense exudate 1S assured by a wide incision. It is natural that the clinical symptoms of cutaneous panaritium should not he confined to a typical region: the site of inflammation may he in the cushion of the finger-tip or at any point on the flexor surfaces, although it is usually in the palm. Subungual and Parungual Panaritium.— These forms are frequently due to slight injuries of the nail-fold and of the nail itself, such as the penetration of small foreign bodies into, or small penetrating puncture wounds of, the matrix, or similar injuries usually regarded by the patient as insignificant. The tenderness is particularly great if the affection develops beneath the nail, whereas as soon as it reaches the dorsum of the finger it diminishes rapidly for the above anatomical reasons, so that considerable pus may collect without causing much pain. The nail is frequently destroyed; its extraction is followed by diminu- tion of the pain and favors recovery. The dressing-forceps or Trendelen- burg's extraction-forceps (Fig. 209) are useful. Fig. 209. Trendelenburg's nail-extractor. Panaritium of the Tendon-sheaths. — This affection, which deserves especial mention, is discussed here purely on practical grounds and in order to avoid otherwise necessary repetition. A glance at the course of the tendon-sheaths in the palm and dorsum (Fig. 173) will show how far inflammatory processes can extend immediately or later. The most important criterion of the affection is its rapid advancement with pain and impaired motion of the corresponding tendon. It is important practically that the flexor tendon-sheaths of the second and fourth fingers very rarely connect directly with the common tendon- sheath of the wrist. The illustration saves further discussion of the anatomy; it teaches that from the flexor tendon-sheath of the thumb the process can spread rapidly up to and beneath the transverse carpal ligament and involve the common tendon-sheath of the remaining flexors as the result of the high pressure of the exudate; it can even invade the tendon-sheath of the little finger, in which case it may advance directly upward upon the synovial sheath of the palm beneath the carpal ligament. The sheaths of the second and fourth fingers, ending almost always at the level of the heads of the metacarpals, usually check the infection at this point. Failure to recognize and expose the exudate in the tendon-sheaths of the latter fingers may mean infection of the palm; the common tendon-sheath, however, is thereby not endangered to the same extent. On the dorsum the tendon-sheaths are not so extensive, so that the inflammation does not spread so rapidly. 324 DISEASES OF THE WRIST AND HAND. In panaritium of the tendon-sheath the swelling extends along the entire finger, the interphalangeal folds are flattened out or effaced and the swelling usually ends distally at the base or the middle of the third phalanx, whereas the tip of the finger may be relatively free; the swelling at the sides and on the dorsum is less distinct. In cutaneous panaritium, in contrast, there is a medial longitudinal swelling on the volar surface. All these symptoms are marked in recent cases of pure panaritia of the tendon-sheaths. They are even more marked in acute gonorrhneal and chronic tuberculous inflammation. The term pure pana- ritium is used because the adjacent tissues — skin, periosteum, and especi- ally the joints with which the tendon-sheaths occasionally communi- cate, are frequently involved if the affection is protracted. Osseous Panaritium. — This primary inflammatory process of the periosteum is included here for the sake of clearness. It is more com- monly the result of small infected puncture-wounds, and, like all affec- tions of the bone and periosteum, is characterized from the outset by intense pain; sleepless nights are the frequent result, as in the sub- ungual form. Naturally the process should give the maximum of inflammatory symptoms in the limited area of a phalanx, and generally this is clearly demonstrated. The swelling, as in diseases of the peri- osteum and bone, is generally cylindrical, but may be more pronounced on the dorsum, where the skin is more yielding. Whereas in the cuta- neous form spontaneous perforation of the pus depends upon the site of infection — and in the tenosynovial form the perforation occurs preferably at the ends of the tendon-sheaths, usually the distal end — in the periosteal form there are frequently numerous fistulas, mostly at the sides of the. finger. If of longer duration, the fistula? show characteristic puffed, rosette-like granulations. If the diagnosis is still uncertain, the probe will demonstrate a sequestrum of the larger part or the whole of the phalanx. Articular Panaritium. — In tins form, which occurs either primarily or secondarily, there is usually intense pain, as in all acute infections of the joints. As the skin over the joint on the dorsum is rarely more than 1.5 to 2 mm. thick, superficial lesions will be close to or penetrate the joint. The acute inflammatory exudate distends the skin on the dorsum into a hemispherical sac; the transverse skin folds are obliterated and the joint becomes semiflexed, the position giving the greatest space to the exudate. If left to itself, the exudate soon produces necrosis of the cartilage and rapidly perforates to the surface; if less acute, namely, in the serous form, it is followed by ankylosis, more or less pronounced crepitus, and pain on motion. Although of rare occurrence, the author knows from numerous careful observations that a pure serous exudate is possible in staphylococcus infection, the inflammation stopping at this stage with gradual death of the bacteria and the preservation of the joint-function. The fever accompanying panaritial inflammation varies, and is some- times ushered in by one or more chills; this applies to all forms of panaritia, but particularly to those of the bones, joints, and tendon- ACUTE INFLAMMATORY PROCESSES IN HAND AND FINGERS. 325 sheaths. The high pressure under which the inflammatory exudation exists, as has been seen in the cutaneous variety, explains the frequenl discrepancy between the height of the fever and the size of the focus in volar panaritia. Formerly the degree of fever was ascribed entirely to these physical peculiarities, but it is known now that it depends greatly upon the kind of bacteria in the tissues, the rapidity of their growth, and the virulence of their toxins. Course. — The duration of the various infections, independent of the anatomical differences of the skin, tendon-sheath, hone, and joint, depends upon the susceptibility and power of resistance of the individual and the virulence and toxicity of the bacteria. In the cutaneous form pronounced necrosis is seen following within a few hours or days, with marked constitutional symptoms, and, if not cheeked at an early period by incision, accompanied under circumstances by the severe general infection. In other cases, days or one or two weeks pass; the use of the hand is little impaired; the patient employs ordinary remedies and incision shows a limited focus; or, it may perforate spontaneously and recovery follow the sloughing of the necrosed tissue. In the tendon- sheaths the process is rather rapid (foudroyant ); the exudate becomes purulent within a few days; the feeble circulation in the tendons is checked and necrosis is the inevitable result. Non-surgical, namely, expectant, treatment of purulent tenosynovitis is hazardous for the later use of the hand and fingers, and, under circumstances, even for life itself. In from three to six weeks the portion of the tendon lying necrotic in the purulent exudate is cast off as a vermiform slough through a fistulous opening forming spontaneously or after incision. The process may stop here; contraction follows, and nothing is able to replace the loss of the tendon. The uselessness of the finger is often an indication for later amputation. If the process advances upward, however, the symptoms of phlegmon of the palm follow, and there may be septic erosion of the vessels; by timely interference it may be checked at this level. Even then it is usually months before the use of the hand is regained. If the suppuration advances upward beneath the carpal ligament and beyond the upper end of the tendon-sheaths, the symptoms may be marked or the process may ad- vance insidiously (often signalized merely by further attacks of fever, weakening the patient) between the tendons and muscles and cause deep phlegmon of the arm. To explore and check the suppuration may tax even the skill of the experienced. Suppuration along the inter- osseous ligament may remain concealed beneath a tense, inflammatory myositis of the flexor muscles; it may perforate toward the posterior surface, cause deep-seated purulent lymphangitis and septic thrombo- phlebitis, and for weeks threaten life. The limb may be saved by incising freely and dilating the openings with dressing-forceps; amputa- tion is sometimes necessary, however, If the process is checked, the result is muscular degeneration, cicatricial shrinkage, contracture, and great impairment of hand and arm. The course and treatment extend over months and the orthopsedic after-treatment often over six 326 DISEASES OF THE WRIST AND HAND. months or longer. The earning-efficieney of the laboring-man is often lost for more than a year. Treatment. — The treatment consists in incising the primary focus as early as possible. It may be difficult to find the focus, even in the cuta- neous form, but exploration is usually facilitated by carefully searching for the point of greatest tenderness. By timely interference the surgeon is in a position to prevent the dangers of further absorption of the infec- tious material, and to limit the focus of inflammation. Even with the law nihil nocere in mind the author is convinced that it is better to incise too soon or too freely than to err in the opposite direction. In cutaneous panaritium, if the centre of the inflammation is not yet denoted by an ansemic or yellowish color of the skin, it is well to determine the most sensitive point with the end of the probe or similar object and make an incision \ to 1 inch long. After incising, a wet dressing of boro- salicylic acid or aluminum acetate, lead subacetate, or salt solution, gives the greatest comfort. The condemnation of wet dressings as being a "damp chamber" encouraging the development of bacteria and thereby the infection should be withdrawn. Their application depends not upon their imputed gross mechanical effect on the bacteria, but upon their physiological action on the vessels of the tissues covered, as is easily studied experimentally. The wet dressing is indicated until the inflam- matory process becomes limited, after which, with regard to the skin, it is better to replace it by an ointment or dry dressing. If the skin is very sensitive, a dressing of salicylic acid, alone or with a slight admixture of zinc sulphate, is advisable from the outset; sterilized or boiled water soon causes eczema. To "plug" the wound with agglutinating powder does not correspond to the ideal physical conditions for drainage. Salzwedel warmly recommends an alcohol compress applied as follows: "An eight-fold strip of muslin, fat-free, is saturated with alcohol, applied to the skin, and covered with a loose dry layer of cotton 1 to \\ inches thick; over this is spread a covering of some perforated, impervious material, and the whole bound with thin muslin or cambric." Ninety- five per cent, alcohol is the best; "weaker should only be used in an emergency." Under the rest of the bandage the skin should be covered with a loose layer of dry, iodoform, or plain gauze. The dressing is usually left on twenty-four hours. A. Schmitt, Korsch, Graser, and others recommend this method. Immobilization of the finger, the hand, or if necessary the entire arm, is in accord with the law of rest in the treatment of all inflammatory processes. If the patient is sensitive or if the infection is ushered in or accompanied by high temperature, rest and suspension of the arm should be prescribed. An ice-bag at the elbow, or better in the axilla, com- pletes the desired antiphlogistic treatment. The author almost always incises under Oberst's local anaesthesia. For panaritium of the palm simple cocaine anaesthesia or Schleich's injection method is valuable, but the author makes it a rule never to use more than § grain of cocaine at once, employing a 4 per cent, solution and waiting a short time for the effect. ACUTE INFLAMMA TOR Y PROCESSES IN HAND AND FING EBS. 327 Frequently it is well to employ general anaesthesia, and after incising the skin to dissect bluntly with the forceps to obtain a wide path for drainage. A fair-sized drainage-tube is usually preferable to gauze, the incision not being made too small — 1 to 1 \ inches — and hemorrhage being checked by appropriate retraction of the edges and ligation. Annoying secondary hemorrhage is not infrequent. In the initial stages of panaritium expectant treatment is still much in vogue, the limb being immobilized, wet dressings or hot poultices being applied, and a posi- tive, purulent dissolution awaited. This method seems to the author to be justified only by accurate determination of the chief source of infection or by great fear of the knife on the part of the patient; the latter will have to pay for his opposition with long-continued pain, great loss of tissue, protracted illness, and severe functional impairment. The great number of other methods, inunction, painting with astringent substances, iodine, ichthyol, etc., have as little justification for being used as the compression methods — founded originally upon the erro- neous idea that they limit the inflammatory swelling — have for being rejected. Unfortunately one not infrequently sees the misuse of carbolic dressings of varying strength at the onset of the process and the resulting carbolic gangrene. (See section on Carbolic Gangrene.) For the tenosynovial variety, early incision is of first importance; it may mean the prevention of necrosis; generally the tendons remain adherent for some time. Occasionally the mobility of the tendons can be restored later if surgeon and patient spare no efforts in the after- treatment: massage, passive motion, baths, finally electricity to the cor- responding muscles, and especially orthopaedic measures. A cicatrix can be made yielding even after months; the endothelium covering the tendon and its sheath possesses great regenerative power. Naturally, firm fibrous adhesions of long standing cannot be replaced by endothelium, so that the orthopaedic measures should follow immediately. Cases of obliteration seen a year or more after the inflammation are hopeless. If the process cannot be checked in the early stages, or if the case is first seen after suppuration or necrosis has begun, the entire focus should be opened by an incision 1 to 1+ inches long. (See Fig. 173.) To scrape out the necrotic tissue before demarcation occurs is not in accordance with our present knowledge of infectious processes; where there is not much to save, but rather new complications can be caused by stirring up the inflammation, the author prefers to confine himself, at this stage, to exposing and draining the focus, and to await separation and sloughing of the tissues. Where and when to amputate a finger rendered useless by complete necrosis of the tendons depends upon the desire and posi- tion of the patient, upon later expediency, or upon aesthetic considera- tions. Generally, in patients or classes dependent upon manual labor the author amputates immediately after the symptoms of inflammation have subsided if there is no prospect of recovering motion. Although the author amputates or resects according to the immediate necessity, he prefers to exarticulate and to suture the flaps with retention sutures. He avoids wounding the spongiosa on account of the possibility of re- 328 DISEASES OF THE WRIST AXD HAND. newed infection that is present for a long time in the previously infected tissues. If the patient comes for treatment, however, with the consequences of previous infection of the tendon-sheaths — stiff fingers — the above considerations do not apply, and the surgeon is concerned merely in obtaining the best possible function; for example, if there is stiffness of the middle finger, amputation of the metacarpal at the neck. Dis- criminative operating has proved its value in the treatment of contrac- tures of the fingers. In the palm the author distinguished between superficial cutaneous processes and the deep phlegmon developing beneath the palmar ap- oneurosis. In the former, simple incision usually brings recovery; in the latter case the knife, or better the closed dressing-forceps, should be introduced between the fibres of the aponeurosis, the blades opened and then withdrawn. Free exit is thus obtained for the pus. The author prefers in the severe forms of deep phlegmon to thrust the forceps through to the posterior surface between the metacarpals, to make a counter- opening, and secure through drainage. It is best to do the operation under anaesthesia. In this way it is often possible to control suppuration existing under pressure beneath the aponeurosis. The increasing hemor- rhage during the operation need not be feared if the trunk of the palmar arch is avoided; if the edges of the wound are forcibly retracted, the source of the bleeding can usually be found. Spontaneous secondary hemorrhage from the eroded vessels in the palm can be more trouble- some. As much as the author objects to applying the Esmarch in phlegmonous processes, it is the best means, in this case, of obtaining a good view of the bleeding area, as the source of hemorrhage can be located by its alternate application and removal. It is in these cases of secondary septic hemorrhage that one has the disagreeable experience of having the clamp repeatedly tear the friable wall of the vessel, fall off, and occasion renewed hemorrhage. The author has always been able to check the hemorrhage, however, without ligating in continuity, in contrast to previous experience. If the process extends tipward beneath the carpal ligament to the subfascial, intermuscular spaces of the arm in the manner described, every newly suspected focus should be attacked with scalpel and forceps — avoiding the nerves and vessels— and drained freely, with care that the drains are not so small as to be compressed by the tense tissues. If free drainage is not obtained at the transverse ligament, the latter should be divided, in view of the danger to the carpal joints. (Helferich, Konig.) Phlegmon in the dorsum, more rare and less serious, requires the same treatment. In the osseous form the separation of the sequestrum should beawaited, possibly an incision made to relieve the pain. This separation occurs in from two weeks to two months, according to the age of the patient, the condition of the circulation and of the tissues, and the amount of necrosis. The sequestrum is exposed by a lateral incision the length of the phalanx — thus avoiding the tendons and the areas of touch — ACUTE INFLAMMATORY PROCESSES IS HAND AND FINGERS. ;]29 and is removed without difficulty. The operation is easy with Oberst's anaesthesia. Packing the small cavity causes it to be rapidly filled in by granulation. The joint-affection, if seen early, recovers best by incising; later, after the formation of fistulas and erosion of the cartilage with crepitus on motion, one should cither encourage ankylosis by immobilizing and keeping the wound open or resect the head of the proximal hone, or both articular surfaces, with Liston's forceps. Recovery is usually rapid and uninterrupted. Sometimes there is fail - motion without pain, then again ankylosis. Acute and Subacute Infections of the Soft Parts of the Hand and Fingers (Non-panaritial). Furuncle. — Owing to the absence of sebaceous glands in the palm, genuine furuncular inflammations occur only on the dorsum. They are often seen in harness-makers, leather-workers, and in those coming in contact with pus and purulent processes — surgeons, dissecting-room orderlies. They do not differ essentially in any part of their course from the other furuncular inflammations except that the lymphadenitis, especially in the axilla, frequently becomes preponderant. The glands running from the axilla to the coracoid process under the pectorals are not infrequently swollen and purulent. The infections accompanied by high fever are due to streptococci, whereas the milder forms are always staphylococcus infections, often the staphylococcus albus, which is so frequently found everywhere in the skin. Treatment. — The treatment is on general principles. The expectant treatment — poultices, dressings of balsam of Peru, etc., till the abscess becomes "ripe" and then incision — still has many advocates. Others incise early to prevent spreading. There is a good deal to be said on both sides, in view of the comparatively slight pain of dorsal furuncle compared to that of volar panaritium, the difference being attributable to the looseness of the skin on the dorsum. If the symptoms are severe, namely, high fever and impending lymphangitis, the author incises and drains, but in the less acute forms he awaits the formation of an abscess, applying wet dressings and immobilizing upon a small splint. The onset of lymphangitis and lymphadenitis demands complete rest and the application of ice in the axilla. The Primary Effects of Syphilis.— The primary effects may be mani- fested for a long while merely as a harmless paronychia. On the fingers the author has only seen it about the nail and in connection with small fissures at the nail-fold. The slow development, relatively slight pain, sluggish appearance of the partially necrotic, punctate granulations, and the absence of epithelial growth along the edges are the chief symptoms. In only one of the cases and at a later period was there induration corre- sponding to the induration which the author is accustomed to see witli the typical nodules of Hunter. The diagnosis is supported further by the slow course of the local inflammation and the very characteristic 330 DISEASES OF THE WRIST AND HAND. form of the associated lymphangitis. There is marked infiltration of the lymphatics on the back of the forearm and the cubital glands are distinctly swollen in the third to the fourth week. Thick, hard, irregular cords run upward in the bicipital sulcus and at the inner side of the biceps. The glands are largest in the axilla and under the pectoralis. The swelling has already begun to recede when the sudden appearance of the general roseola in the sixth to the ninth week after the infection makes the hitherto possibly doubtful diagnosis unavoidable. The tem- perature, observed commonly in syphilis at the time of the appearance of the hard chancre and the constitutional symptoms, is also met with here in the form of irregular febrile movements. Still the exacerbations stand in no direct relation to the extent and severity of the lymphatic infiltration. Treatment. — Naturally the treatment does not differ from that of the ordinary infection, and an incision upon the increasing and occasionally pseudofluctuating infiltrate would not have the desired effect. Erysipelas. —It may be surprising to know that the author has rarely seen true erysipelas in the fingers and hand. If with Billroth one regards erysipelas as a superficial lymphodermatitis, the conclusion is justifiable that the relative infrequency of the disease depends upon the arrange- ment of the cutaneous lymph-spaces of the hand and fingers. Oppor- tunities for infection are not lacking, yet the author may say that genuine erysipelas is as rare as panaritium is frequent. The clinical course is almost always characterized by rapid advance of the erythema and high temperature. Treatment. — The author foregoes every operative measure; provides for rest and elevation of the limbs, and relaxation of the skin by means of wet compresses renewed two or three times daily if possible, and incises only in case of pus. The diet should be restricted. This is not the place to discuss the occasional danger of extension of the infection, as in that case the surgeon has to deal with processes involving more than the hand and fingers. Pseudoerysipelas. — By pseudoerysipelas, or erysipeloid, is under- stood an affection of rather frequent occurrence, similar in its symptoms to erysipelas, but differing in its etiological and prognostic significance. In it there is also a superficial lymphangitis. The affection is acquired almost without exception in kitchens, meat-shops, fish- and game-shops, etc.. and is always found to be caused by slight wounds from fish-bones, lobster-shell-, splinters of bone, etc., if recognized by the patient. Symptoms. — The congestion is the most prominent symptom, develop- v I an- I or insular slowly upward with deep cyanosis or copper coloring of the skin, and accompanied by more or less intense pain. The infiltration is glistening, well-defined, and projects in places above the level of the skin. There are no serious constitutional symptoms or swelling of the glands of the arm, an important point in the differential diagnosis. For years the author has described this affection to students as a pronounced local toxic process, the cyanotic congestion being the result of local paralysis of the vessels. From our present knowledge of ACUTE INFLAMMA TOR V PROCESSES IN HAND AND FINGERS. 331 the condition it is easy to conceive thai ferments, adherent to the above- mentioned dead pieces of fish or flesh, and inoculated into the skin of the finger through a small wound, are carried into the superficial lymph- spaces, producing paralysis of the vessels varying according to the amount and toxicity of the ferment. Prognosis. — The prognosis is always good, and the patients, anxious on account of " blood-poisoning," can be convinced in two to four days of the harmlessness of the trouble by making a small incision at the point where the supposed poison has found it- strongest expression and by immobilizing the part. It should he emphasized that operation is not necessary. Lymphangitis and Phlebitis.— Lymphangitis, in the strictest sense, has been mentioned repeatedly in connection with panaritium, furuncle, and erysipelas. According to the old clinical use of the term, the author still understands merely the infection as manifested by the classical red streaks following the course of the larger lymphatics along the extremity. It should be borne in mind, however, that all diffuse diseases of the superficial and deep tissues, whether in the trunks or the free capillary network of the lymph system, are in the main lymphangitic. One's ap- preciation of the affection is best aided by the old well-known idea of His, representing all the cellular tissue elements as swimming in a sea of lymph. By far the greater number of infections are conveyed by the lymph in its smallest intercellular channels and streams. The red streaks of this form of lymphangitis are not recognizable in the skin of the hand and fingers except on the dorsum and on the volar surface of the wrist. This subject therefore carries us beyond the region of the hand; still it should be mentioned, as the hand is the most frequent starting-point of lymphangitis of the arm. It is almost always a streptococcus infection which causes the lymph- angitis, and usually follows small foreign body, puncture- or tear- wounds, and the like, or is the result of extensive suppuration. Con- tinued use of the extremity after the injury, or after the infection has already been established, has doubtless much to do with the production of the lymphangitis. Later the infection is by no means always limited to the lymphatics, but infiltrates the adjacent tissues. After the acute symptoms have subsided the author often finds more or less painful cord-like lines of infiltration the size of a lead-pencil, especially on the anterior surface of the extremity, which may last for weeks or months. The "dissector's lymphangitis" of the upper extremity, a cadaver infec- tion (usually streptococcus*, is properly regarded with fear; it starts with frequent chills, or, in contrast, the local process spreads steadily with almost complete a pyrexia. The lymph-glands either suppurate slowly or painful swellings persist without recognizable suppuration. Renewed chills at the end of several weeks suddenly signalize insidious metastases in the body, endocarditis, pleurisy, etc. The prognosis of these phleg- monous processes, especially those of the palm, may be made serious by the infection becoming general from a phlebitis and periphlebitis. 332 DISEASES OF THE WRIST AND HAND. FEOST-BITES AND BURNS. In addition to the general symptoms of frost-bites and burns, which will not be discussed here, certain local symptoms should be mentioned on account of the frequency with which the fingers and the hand are involved. Frost-bite. — In cases of freezing the capillaries dilate from the action of the cold and then contract from the irritation of the skin ; then follow changes in the blood, muscular rigidity, necrosis of the contractile sub- stance, and nuclear degeneration. (Kraske, Volkmann.) While the freez- ing lasts it is not possible to determine the amount of damage. After the parts have, thawed, according to the degree of freezing there may be: red- ness and swelling with temporary dilatation of the capillaries (congela- tion erythema, first degree of frost-bite); or separation of the epidermis, vesicles, from the exudation caused by stasis, accompanied by super- ficial loss of substance (second degree) ; or gangrene of the skin of part of or the entire limb (third degree). Anaemic and chlorotic people are especially susceptible and are frost- bitten by a degree of cold which has no effect upon healthy persons. If the gangrene is limited to the skin, cicatrization sometimes follows after prolonged ulceration, such as is common if the destruction is deeper. Frost-bite gangrene of large areas brings all the dangers of septic and toxsemic complications connected with every case of gangrene up to the time of demarcation. Prognosis. — The prognosis should be given guardedly. Treatment. — The treatment depends upon the severity of the lesion and is on general principles. If there is extensive "wet" gangrene and severe symptoms of toxaemia, life may be saved by amputating in sound tissue. In cases in which limitation occurs early, demarcation is awaited and then amputation performed. The so-called chilblain is characterized by chronic circulatory changes, diffuse or nodular erythema, and swelling with intolerable itching in a warm atmosphere. The secondary ulceration from scratching may resist all treatment. Disappearing in summer, the swellings return in the fall and winter with the same annoying symptoms. The well- intended advice "to avoid all exciting causes as much as possible" is usually rendered impracticable by the occupation of the patient. Baths with a slight admixture of hydrochloric acid; protecting the skin with ointment or plaster if there are ulcers; the silver nitrate stick, and pro- tective dressings, may be tried alternately. For frost-bites the general rule is the application of gradually increas- ing warmth and elevation of the arm to overcome venous stasis. The circulation is often thus restored, so that parts are saved in which gan- grene was expected. It is impossible to estimate with certainty just how far the result of frost-bite is to be ascribed to mechanical factors. Ritter regards the hypersemia as an attempt at repair on the part of the body of the injury CHRONIC INFLAMMATIONS OF HAND AND FINDERS. 333 produced by the cold. The hyperemia results from capillary attraction analogous to that occurring after application of the Esmarch; it has been described very clearly and graphically by Bier. Accordingly Hitter recommends Bier's venous congestion method for acute frost- bites, and for the chronic effects of the cold, arterial hyperemia by means of hot air applied for one-half to one hour. Burns. — Burns of the hand and their treatment are to be regarded essentially from the point of view of general pathology and therapeutics. Especial attention should be called to the severe contractures and synechia 1 between the fingers often following deep burns. Extension- contractures of the fingers are especially common on account of the frequency with which the dorsum of the hand is affected. Such con- tractures are prevented very little by antagonistic dressings, therefore grafting should be done as soon as the granulations are clean; later, appropriate passive motion, massage, and antagonistic apparatus may do much good. Fully established contractures demand removal of the cicatrix in sound tissue, forcible retraction of the edges of the wound, and skin-grafts or flaps. Even then the result is permanent only when appropriate exercises follow the healing over of the surface. Usually the older the contracture the more difficult it is to obtain a complete functional result. Nothing can be done if there are changes in the joint or if the tendons are destroyed. CHRONIC INFLAMMATIONS OF THE SOFT PARTS OF THE HAND AND FINGERS. Eczematous and mycotic-parasitic affections of the skin have passed more and more into the domain of special pathology. Still the author feels that he ought not to omit to mention that, if there is any evidence that the disease is caused by a local agent that is accessible, recovery is best obtained by energetic removal of the latter — e.g., if caused by drugs, by removing the last traces chemically (iodoform by ether) ; if from dirt, by thorough mechanical cleansing, under an anaesthetic if painful. Of the diseases of the nail belonging to surgery, the subungual panaritium has been discussed. Chronic affections of the nail now belong to dermatology. The pathology of the nail is treated compre- hensively in J. Heller's Krankheitcn der Niigel. The chronic effects of subcutaneous coccus infections and furuncular and septic diseases of the skin are usually recognizable by their local limitation, the history, the general habit of the patient, the fresh granu- lations, or the profuse suppuration. Their treatment is that given for panaritia. Tuberculosis of the Skin. — Tuberculosis occurs in the skin in many forms. The dorsum of the hand and fingers is the usual site. The infiltration may develop slowly, the skin being dry and scaly; or exist for a long time without symptoms of acute inflammation, the skin being smooth, of brownish-red color, and frequently with single nodules in 334 DISEASES OF THE WRIST AND HAND. the adjacent parts; or there may be a lupus extending diffusely over hand and ringers with doughy swelling, thick infiltration, and small or large superficial ulcers, the base of the ulcers being covered with dirty, milk-gray, anaemic granulations, necrotic in places. Or the tubercu- losis may be manifested as deep ulcers, the size of a quarter or dollar, with eroded, undermined edges and uneven base covered by a waxy membrane if neglected; if clean dressings are applied, the secretion may be slight. Lupus is especially important surgically if it produces ulcera- tion and cicatrization leading to contractures and mutilation of the fingers, in which case the term "lupus mutilans" is proper, v. Langen- beck at the Fourteenth Surgical Congress was able to demonstrate only one case; Doutrelepont reported its great frequency in the Rhine districts; and Kiittner stated that in 19 cases of lupus of the hand obtained from the literature of forty years there were only 10 instances of contracture Deformity due to lupus; contracture of the third, fourth, and fifth fingers in extension and adduction (ulnar inflexion). and deep destruction. In spite of the enormous frequency of skin, bone, and joint tuberculosis in Saxony the author has had only 3 cases of pronounced mutilation from lupus in his large material in Leipzig. (See Figs. 210 and 211.) As lupus occurs and spreads chiefly on the back of the hand and fingers, the hyperextension-contractures develop always over the meta- carpophalangeal joints, with secondary subluxation. The tendons generally remain intact, the cicatrix in the skin causing the contracture. The inflammatory changes resulting in the joints are not tuberculous, but are deforming processes resulting from disuse; they may produce complete bony ankylosis. Sometimes lupus is found near depressed bony cicatrices in the phalanges or metacarpals or near corresponding fistulas. In all the above forms the diagnosis is usually supported by the general habit and youth of the patient, and by suspicious multiple lesions on the rest of the body. It is different in the cases in which the CHRONIC INFLAMMATIONS OF HAND AND FINGERS. 335 history and symptoms indicate an immediate infection of the skin from without. The lesion is then usuallythe verrucous or hypertrophic form. 1 Pig. 212.) The active proliferation of the epithelium is manifested by wart-like growths, or there may be bridges or a grating of several Fig. 211. Lupus mutilans, (v. Bruns.) bands of epidermis — due to partial ulceration of the dermis — which can be lifted off with the probe. The starting-point of this process was referable almost with certainty in one instance to a cut from a piece of glass, in another to the bite of a cat, and in 5 others to the occupational Fig. 212. Tuberculosis verrucosa, (v. Bruns.) injury of butchers who had come in contact with tuberculous meat. Surgeons and dissecting-room orderlies are exposed to a special form of the infection, cadaver-tuberculosis, developing usually in the form of papillomata. 336 DISEASES OF THE WRIST AND HAND. Treatment. — The author is glad to be able to state that recently more of the dermatologists are advocating radical treatment. True to the principle: tuberculosis is surgical wherever easily accessible and remov- able without severe functional loss, the author recommends excision of the parts involved and grafting, or covering in with pedunculated or whole-skin flaps. After carefully excising all diseased tissue with a margin of sound tissue — avoiding reinfection of the wound — the edges are well retracted, the fingers immobilized in flexion upon a splint, and the wound grafted so that the space covered is excessive and the result- ing cicatricial contraction will be compensated. The author has also obtained excellent results with Krause's corium- or whole-skin flaps. The author has never seen a cure with the .r-ray, recently so widely recommended for the treatment of lupus. Kiimmell and others report final cures by irradiation, the cicatrix being particularly satisfactory from an aesthetic point of view. Typical tuberculous lymphangitis of the upper extremity, arising from tuberculous affections of the hand or fingers, is extremely rare. Ever since Karg and Merklen stated in 1885 that tuberculous foci on the surface of the body could cause superficial tuberculous lymphangitis — lymphangitis tuberculosa externa — French investigators in particular (Morel-Lavallee, Lejars, and Goupil) have studied and described the clinical side of this process. Jordan has given a detailed and compre- hensive description of the infection. Many of the patients had never had tuberculosis before or ever been sick. The larger lymphatics are changed into firm cords, soon becoming adherent to the adjacent tissues and presenting three, five, eight, ten, or more nodular swellings in their course, sometimes in the form of a rosary. Later the thickenings give fluctuation; the overlying skin becomes attenuated, of a bronze or bluish color, scaly, and may rupture and ulcerate. The corresponding glands are almost always infiltrated. Syphilitic Affections. — These are either primary effects, as described above, or occur in the form of fissures with a waxy coating, and develop into chronic paronychia at the nails or in the interdigital folds. Gum- matous infiltration is rare and is characterized by a painless flat swelling, of a light-brown color projecting above the surface, and usually movable upon the underlying parts. Dactylitis syphilitica, first described by Liicke as a disease of the fingers in the tertiary stage, is a diffuse uniform thickening of several phalanges, sometimes of several fingers, which obliterates all the folds of the skin. It advances over the joints and involves them. The skin is usually of a brownish, copper color, red at the onset, at the same time very tense, elastic, and almost painless. Although the process may involve the capsule of the joint at one or more places, motion is usually retained and without crepitus. This circumstance should indicate its relative benignity, and on longer observation be decisive against tuber- culosis. The diagnostic importance of syphilitic psoriasis of the palm has been recognized for a long while. Syphilitic ulcers, following disin- tegration of a gumma, with soft, elastic, ragged edges, and burrowing X - < o '55 > 5 0> cc a o j- z CHRONIC INFLAMMATIONS OF HAM) AND FINGERS. 337 out holes in the skin, are occasionally met with on the hack of the hand. Trophic Disturbances. Under Serious Results of Wounds the author mentioned sonic of the essentially trophic disturbances, glossy skin, atrophy of the muscles* There is also a rare, severe trophic dis- turbance of great surgical interest, characterized by ulceration and gangrene. The simplest form of trophic necrosis and ulceration, and the one whose etiology is best known, is found, especially on the volar surface of the fingers, following injuries of the peripheral nerves. If the site of division of the nerve is beyond the exit of the muscular branches, the disturbance is sensory — anaesthesia — not motor-functional. It is characteristic of the gangrene following such wounds that it is very often localized in the skin on the surfaces of the finger used in grasp- ing objects. These localized trophic ulcers give one the impression that they are apparently analogous to bedsores. Suture of the nerve brings about complete recovery if not done too late after the injury. Fig. 213. Trophic changes in the thumb and index finger following puncture-wound of the median nerve. Local Effects of Syringomyelia and Leprosy. — These diseases cause severe trophic disturbances in the skin of the hand and fingers and on account of the anaesthesia lead to panaritia and phlegmon. The changes in the bones and joints will be discussed under Chronic Affections of the Bones. The changes caused by gliomatosis — Morvan's disease- sometimes remind the author of the analogous diseases already men- tioned, namely, analgesia of the inflamed and suppurating area, usually complete; simultaneous nodular swelling of the joints; deformities and atrophy, or defects in the phalanges. The examination for disturbances of temperature-sense and muscular atrophy in the affected limb- always demonstrates the central origin of the disease. In 4 of the author's cases of syringomyelia occurring between the twenty-first and forty- eighth year he found such phlegmonous affections. The swelling of the inflamed area always suggested a low-grade elephantiasis; it usually became circular rapidly, and was characterized by its slow course and persistent elevations of temperature, the patient being not essen- tially weakened thereby. The patients often go about for a long time with such panaritia, as the disability is slight on account of the analgesia. The treatment differs from that of the otherwise analogous diseases Vol. Ill— 22 338 DISEASES OF THE WRIST AND HAND. Tig. 214. in that one decides more easily to amputate a finger or part of it to remove the deformity and cheek the process. Syringomyelia and leprosy often give very similar symptoms in the hand, The panaritial and lymphangitie processes in leprosy, sometimes accompanied by analgesia, are of interest to the surgeon. They usually supervene upon the ulceration of leprosy, which latter is characterized by its sluggishness, rather thin discharge, alternate healing and recur- rence, later involvement of the bone with the production of sequestra, and possibly loss of single phalanges, fingers, or even the hand (lepra mutilans). Or there may be wasting of the tissues with almost no symp- toms of inflammation, but with the production of the above deformities. Thus the terms atrophy and con- sumption of the bones of the phalanges have been applied. (Balz.) There may be spots of dry or wet gangrene. (Kaposi.) The rare affections, symme- trical gangrene of Raynaud and ergotism, are of only slight sur- gical interest, although their etiology is still obscure. Kaposi regards the sclerodac- tylia of French authors (Ball, Hallopan, and Lepine) not as a special form contrasted to the first stage, sclerema with thick- ening — sclerema elevatum, but rather as the second stage of scleroderma — sclerema atrophi- cans. In it the skin of the finger becomes thinner, like parch- ment, glossy red, sprinkled with pigment, extremely tense and adherent. The entire subcu- taneous fat-cushion disappears, the skin is like stretched rubber, and the underlying bones are adherent. Defects, ulGers, and gangrene follow. Recovery at this stage is impossible. Amputation of the affected fingers ameliorates the pain, presupposing that it is limited to the finger or hand. Presenile and Senile Gangrene. — These affections occur more fre- quently in the hand and fingers than in the toes and the foot. They may be signalized by nervous and circulatory prodroma : itching increas- ing to severe pain, sensation of coldness, and some rigidity during active movements. After ischa?mia has existed for some time small sero- purulent vesicles appear, accompanied by anaesthesia and severe pain, and followed by dry gangrene and total necrosis of one or more fingers. Deformation of the hand due to syringomyelia, (v. Bruns.) CHRONIC INFLAMMATIONS OF HANI) AM) blNOKIlS. 339 What is termed spontaneous gangrene is usually the result of a, hyaline thrombosis (v. Recklinghausen ), or an embolus in tissue normal up to its site, whereas senile gangrene is always associated with arteriosclerosis and follows the gradual development of changes in the circulation. The picture, as drawn by v. Winiwarter, of obliterating endarteritis with subsequent gangrene, in which there is primarily a growth of the intima, is regarded by v. Zoge-Manteuffel and his pupil Weiss as signifying that the occlusion of the vessel is due to thrombosis of the vessel at the site of changes produced by the sclerosis. Based upon investigations in v. Eiselsberg's clinic, Bunge sides with v. Zoge-Manteuffel, in that he regards Fig 215 X-ray picture of Fig. 214 the diffuse or localized sclerotic changes of the intima and the ascending thrombosis due to the resulting stenosis as the essentials of the process. Although these changes in the vessel are of greater vital significance in the lower extremities, their knowledge is indispensable in diagnosticating analogous affections in the fingers. Diabetic Gangrene. — Gangrene of the fingers or hand in diabetes is more serious and usually extends rapidly. Slight wounds, small unnoticed scratches, permitting the entrance of bacteria, may be the starting-point of extensive destruction of the tissues. This phlegmonous necrotic form of gangrene must be distinguished from the less frequent 340 DISEASES OF THE WRIST AND HAXD. variety occurring without injury, and in which presumably there are important changes in the vessels, as in the presenile variety. Konig and Kraske have demonstrated that in phlegmonous diabetic- necrosis there must be an external cause — bacteria — in addition to the internal cause of diabetes. The recent investigations (v. Xoorden, Xau- nyn, Gross, and others) of carbuncles have confirmed this and proved that the foudroyant necrotic diabetic phlegmon is always accompanied by pyogenic cocci, almost always Staphylococcus aureus, rarely albus. The author has also made the bacteriological control in quite a few cases. The necrosis reminds one of the white, glossy, gelatinocaseous necrosis pro- duced by Vienna paste. In dry gangrene, possibly in the diabetic form produced by arteriosclerotic changes in the vessels, there is a parchment- like eschar. Xaunyn saw a man seventy years old with ulcers on the right index and little finger similar to perforating ulcer, with sharp border and waxy base, which were referable to diabetes; the ulcers were Fig. 216. Diabetic gangrene of the dorsum of the hand. found healed at the end of eleven months. Gross has recently published a careful monograph on diabetic gangrene and collected 49 instances of so-called idiopathic gangrene in 50 cases of inflammatory necrosis of the extremities; 35 were in the lower, 15 in the upper. In 36 there was latent diabetes. The age varied between twenty-eight and seventy- three; the percentage of sugar from to 10 per cent. In the idiopathic forms the gangrene begins usually in the peripheral parts of the extremity, the finger-tips; in inflammatory diabetic necrosis it is located anywhere in the hand, depending on the site of the etiolog- ically important but slight injury. In Fig. 216 is shown a case of acute diabetic inflammatory necrosis on the back of the hand which was under careful observation from the onset. There was 6.7 per cent, of sugar. In six days the extensor tendons were denuded of skin over a large area and partly involved in the necrosis. The process then stopped and recovery followed without radical surgical measures. PLATE XII Carbolic Gangrene of Finger. (Harrington. CHRONIC INFLAMMATIONS OF HAND AND FINGERS. 341 Treatment. — In 1884 J. Hutchinson proposed high amputation — shoulder-joint — for all cases of senile and diabetic gangrene. In 1891 L. Heidenhain made a similar proposal in regard to the lower extremity. The indication fixed by F. Konig in 1887 may be presented as the one generally adopted at the present time by German surgeons for surgical treatment, namely, individualization from case to case and the trans- formation of the septic necrosis as far as possible into an aseptic wound. If phlegmon occurs, it should be incised and the necrotic parts removed as much as possible without injuring the still intact tissues. If the gangrene advances in spite of antidiabetic and appropriate local treat- ment and the general condition is evidently worse, the preservation of life demands high amputation, the author adds, without general anaes- thesia — diabetic coma — but by using morphine and local anaesthesia. In the author's experience the amount of sugar is not decisive for the time and extent of operation, but under all circumstances should deter- mine the energy of the antidiabetic diet. Fig. 217. Line of demarcation of gangrene due to carbolic acid. Carbolic Gangrene. — The author desires to mention here an artificial form of gangrene, the occurrence of which, in no respect less frequent at the present time, is due to the faith of physicians and the laity in the omnipotence of carbolic acid. The fact that solutions of carbolic acid are still sold at retail without a prescription, the ambiguous directions of the physician for its use, and ignorance or misunderstanding on the part of the patient, are responsible for the present existence of carbolic gangrene. According to the statistics of Honsell in 1897, comprising only 48 cases — the author has at least 4 or 5 new cases every year — the strength of the solution used was 1 to 5 per cent, in 30 cases and concentrated in 31. It is of special, practical importance to know that gangrene may be pro- 342 DISEASES OF THE WRIST AND HAND. duced by the application of a 1 per cent, solution for twenty-four hours (case of v. Brims and Peraire), in twelve hours by a 2 per cent, solution (case of Levai), and in three to four hours if more concentrated (case of Kortiim). Without attempting to describe or analyze the various efforts made to determine the pathogenesis of carbolic gangrene — Kor- tiim regarded the cause as neuroparalytic — the author regards Franken- burger's explanation as most worthy of consideration: the epidermis is destroyed, the subcutaneous tissue shows considerable transudation, the contents of the lymph- and blood-vessels are coagulated; gangrene follows the thrombosis of the vessels. The experiments of Levai and Honsell make it very probable that the action of carbolic acid is not a specific one, but is analogous to that produced by mineral acids. The danger threatened by the changes is little recognized by the patient: itching and paresthesias merge slowly or rapidly into anaes- thesia. The former is regarded by the patient as an expression of the healing process; the latter deceives him as to the danger. A dull feel- ing of pain is perhaps provocation for changing the dressing, previously so soothing; the finger is yellowish-white or brownish, stiff, cold, and without feeling; gangrene is complete. Individual disposition probably plays a certain part, as the author remembers in his experience in the period when carbolic acid was still used in the treatment of wounds and a difference in toleration was noticed. The only measures to be considered are amputation, exarticulation, or to wait for demarcation. DISEASES OF THE TENDON-SHEATHS AND BURSjE OF THE HAND AND FINGERS. On diagnostic and practical grounds the acute inflammations and suppuration of the tendon-sheaths of the hand and fingers were consid- ered under Panaritium, to which the reader is referred for the acute inflammatory processes of traumatic and infectious origin. Acute serous tenosynovitis is often seen as an affection of the extensor tendons of the thumb accompanied by crepitus on motion (tendovagi- nitis crepitans). It results from trauma or overexertion, and is frequently seen in women of the laboring classes (washerwomen, charwomen); among men it is more common in joiners, carpenters, and locksmiths. It is characterized by a swelling corresponding to the course of the extensor tendons of the thumb, and may apparently involve the muscles. The crepitus, from which the disease derives its name, is caused by loosening of the synovialis and by thin deposits of fibrin. Rest usually brings about recovery in a few days or at least alleviates the pain; if protracted, massage and use are beneficial. Extravasation of blood may occur in the large volar tendon-sheath beneath the transverse carpal ligament, in the common extensor sheath on the dorsum, and in the sheaths of the extensors carpi radialis, in connection with contusion of the wrist or fracture of the radius. The tension may cause severe pain and the restricted movements of the ten- DISEASES OE TENDON-SHEATHS OE HAND AND FINGERS. 343 dons occasion functional loss. The conformation of the swelling depends naturally upon its situation and extent. Traumatic serous effusion is often seen at a later period after injury — e. cj., in the common flexor tendon-sheath after fracture uniting with displacement, the tendons pass- ing over the point of fracture as over a fulcrum and being thus subjected to constant pressure during motion. It also follows subcutaneous injury of the tendon which has produced cicatricial thickening of the tendon or other palpable changes. Tuberculosis and (/ouorrlura, exceptionally syphilis, are the most fre- quent causes of large effusions in the tendon-sheaths of the hand and fingers. The characteristic form and extent of the swelling in traumatic and acute infectious diseases of the tendon-sheath have already been em- phasized as important in the diagnosis; these characteristics are even more striking in chronic inflammations of the tendon-sheaths. The form of the swelling on the volar surface of the finger down to the base of the end-phalanx is particularly well-defined; it may be less distinct if con- fined to the palm, namely, to the distal portion of the common flexor Fig. 218. J Hygroma carpi tuberculosum. (v. Bruns.) sheath. In the latter situation it has naturally to overcome the resist- ance of the palmar aponeurosis; the hollow of the palm maybe partly or entirely effaced; in fact, the skin may bulge convexly. Usually, how- ever, the inflammation and effusion extend throughout the entire flexor sheath and upward under the transverse carpal ligament, ending above in a curve convex upward. The term " pursc-hygroma" (Zwerchsackhygrom) was frequently ap- plied formerly, without regard to the etiology, to the hour-glass-shaped fluctuating tumor bulging above and below the transverse carpal liga- ment. The peculiarity of the swelling is the through-fluctuation beneath the ligament. Often one can feel free or pedunculated rice bodies — corpora oryzoidea — in the sac. Their almost constant tuberculous origin was first demonstrated by Konig and Riedel, and later confirmed by numerous investigators (Goldmann, Garre, and others). The analogous process is seen rather often in the common dorsal tendon- sheath of the extensors or in one of the smaller dorsal sheaths. The author has repeatedly seen symmetrical tuberculous effusions in the 344 DISEASES OF THE WRIST AND HAND. large dorsal and volar sacs, which were spongy and bulging; once there was simultaneous effusion in the tendon-sheaths over the ankle-joint. It is remarkable that these multiple affections of the tendon-sheaths often occur in persons who otherwise show no sign of tuberculosis. This circumstance may excuse the fact that they are often regarded as articular rheumatism and treated as such; still, the error can only arise from careless examination. The tuberculous swelling may occur in the form of a serous effusion, or with rice bodies, or as the doughy, fungous variety. These three forms may represent three stages in the course of one and the same disease, so that they merge into each other and cannot always be distinguished. The first and second categories may continue for months without change and without troubling the patient especially; in other cases the disease Fig. 219. Total excision of tuberculous tendon-sheaths (taken during operation) may be in the form of doughy and more or less circumscribed foci from the start, and when the adjacent tissues are apparently involved it should arouse suspicion that the joint may be affected. This latter form almost always advances steadily to the formation of cold abscesses, perforation, and fistulas. Injection of iodoform and similar measures work wonders in some cases, in others they fail entirely, and the process advances — often apparently more rapidly. If the tendon-sheath is opened, the picture of the destruction is complete: the reddish-blue, spongy, swollen synovialis shows punctate or diffuse degeneration, the cavity is filled with pus and small necrotic particles. In the serous form, iodoform, as mentioned, is of incontestable value. The rice bodies can be removed to a large DISEASES OF TENDON-SHEATHS OF HAM) AND FINGERS. 345 extent by scraping out the tendon-sheaths. In the severest fungous form with disintegration, radical extirpation of the sheaths rarely fails. The Cases in which careful dissection of all or almost all the tendon-sheaths of the palm was indicated were numerous, and after some experience the author can say with satisfaction that the functional recovery of the hand was gratifying in every case, and often remarkable. Fig. 21!) is a picture of a case of very extensive tuberculosis of the tendon-sheaths, taken during operation, after complete removal of all diseased tissue. It was the left hand of a laborer. Today, at the end of three and one-half years, lie has his full earning-efficiency. If left to themselves, tuberculous inflammations of the tendon-sheaths show little tendency to recovery, but increase slowly or rapidly with loss of function and all the symptoms described above. Following per- foration and the formation of fistulas, the tuberculous "tumor" shrinks partially and the patients, especially if advanced in years and the affec- tion is on the left hand, are more pleased with the result than with any plan of operation. It is also in old age, where active proliferation of connective tissue against the inflammatory process is often absent, that iodoform often fails to act; on the other hand, total extirpation is less advisable for very much the same reason. A single small incision may be made to bring about the desired decrease in the swelling, although fully recognizing that its action is merely palliative. Immobilization, baths, care of the fistulas, and injections — 1 per cent, solution of silver nitrate — make the condition more tolerable to the patient. Gonorrhoea! inflammation of the tendon-sheaths is frequently seen among the large material of great cities. It is more common in men than in women, analogous to gonorrhoeal arthritis. It occurs commonly in the third week to the third month of the urethritis, often acute, with very severe pain and corresponding symptoms of inflammation, or it is more subacute. The rapid involvement of the adjacent tissues, (edema, and the serous exudation in the corresponding muscles are characteristic. Further, the involvement of a single joint, with evidence of gonorrhoea, in youthful individuals otherwise healthy, the rapid loss of function, the darting pains of the inflammation, make the diagnosis comparatively simple. The pain in the acute stage may be so severe that aspiration of the inflammatory exudate, as in gonorrhoeal hydrocele from epididymitis, repeated within a few r days, is the most effective measure against it. The author has never found provocation for further operative measures in gonorrhoeal affections of the tendon-sheaths. Absolute immobilization for one to three weeks, then an effective course of movements, is the therapeutic cardinal regime of these affections. The author immobilizes generally upon a plaster or pasteboard splint, exerts slight compression in applying the bandage, and advises elevation of the arm and ice upon the hand. No time should be lost in commenc- ing motion after the pain has disappeared. Otherwise neglect is paid for by ankylosis and functional impairment for a long period. There is a great tendency to adhesions, on account of the pronounced pro- liferative reaction of the connective tissue. 346 DISEASES OF THE WRIST AND HAND. Syphilitic affections of the tendon-sheaths are rare. They are usually seen in the secondary and tertiary stages, and are characterized by uniform elastic resistance or flat exudates. Functional impairment is usually absent. The other manifestations of lues are generally not want- ing, especially in the periosteum and bones (skull, long bones); also gumma of the muscles (trapezius, sternocleidomastoid, pectoralis, etc.). The iodides are of first importance. Bursas are rarely found developed on the dorsum of the hand or fingers; they are occasionally seen over the interphalangeal joints in laborers. Inflammatory effusion in a bursa may simulate an affection of the joint. Chronic thickening of the walls leads to the formation of a small, round hygroma, which may require operation. DISEASES OF THE JOINTS AND BONES OF THE HAND. Acute Inflammation of the Joints and Bones of the Hand. — Acute inflammation of the wrist-joint, as of all the joints, begins with effu- sion and sharp, throbbing, weakening pain. All acute exudates distend the capsule throughout, so that at all spots where its distensibility is not limited by tendons and ligaments it bulges more or less distinctly at both sides of the extensor and flexor tendons. Through-fluctuation from the dorsum to the volar surface is frequently palpable. Large exudates force the hand into a position of slight flexion and usually moderate ulnar adduction. The tendon-sheaths are compressed, the tendons less movable, and movements of the fingers are painful. The soft parts covering the joint are usually oedematous, red, and tense. The affection can be mistaken for one of the soft parts or of the tendon- sheaths alone; but the circular character of the swelling, the pronounced functional loss, the usually intense pain, not infrequently accompanied by high fever, leave no doubt as to the presence of an affection involving the joint. Traumatic exudates, characterized by sanguineous or serosanguineous fluid, are not to be regarded essentially as inflammatory. Earlier they were not always sharply distinguished from genuine inflammations, but the present accurate conception of the etiology and the infectious char- acter of all acute inflammations of the joint make the distinction possible. "Rheumatism," an acute infectious disease of the joints whose etiology is uncertain, is a subject for internal treatment. Surgical treatment will be required only for immobilization, prevention of de- forming contractures, or the improvement of existing deformities. Gonorrhoea, in the majority of cases, is the cause of the monarticular inflammations regarded earlier as rheumatic. The inflammatory ex- udate in the joints of the hands and fingers usually appears at the earliest in the fourth week of the acute urethral infection, and in the later course of the disease generally in the second to third month after the onset. Occurring later in the course of chronic urethritis, it often follows instrumentation or irrigation of the urethra. The large majority DISEASES OF THE JOINTS AND BONES OF THE HAND. JJ47 of cases arc male patients. The affection is characterized by early involvement of the adjacent tendon-sheaths, serous infiltration of the soft parts, and an indistinct picture of an intra-articnlar inflammation. It has a marked tendency to produce early ankylosis and inflammation of the cartilage with crepitus. Symptoms of sepsis are rare. The above symptom-complex is repeated in all cases, with varying acuteness of the symptoms and intensity of the pain. The prognosis of a gonorrhoea! joint is usually good, providing that the treatment begins early and not in the stage of ankylosis or pronounced crepitus. If the surgeon confines himself closely to the therapeutic regime mapped out by Nasse, gonorrhoea! arthritis of the hand and finger-joints presents a grateful domain for treatment. The plan of treatment culminates in two chief points: careful immobilization in the stage of acute pain and prompt commencement of motion after the pain subsides; or, to express it more clearly as to time: absolute immo- bilization till the third or fourth week, then gentle passive motion, and later active exercise. If there are considerable tension and pain, aspira- tion, partial or total, with a Pravaz or a larger needle, gives relief. It may be done at the wrist, at either side of the flexors, and repeated two or three times. The author usually aspirates at the same point used for injecting iodoform, namely, below the styloid process of the ulna. In septic infection the treatment must be more energetic, regardless as to whether the condition is due to penetrating wounds, phlegmon, tenosynovitis, adjacent osteomyelitic foci, metastases, or a general in- fectious disease. The rapid exudation, existing under high pressure, may be the starting-point of further severe complications, the long protracted septic synovitis being almost always followed by synovial synechia?. The time at which the cartilage is destroyed is beyond cal- culation. On the other hand, early removal of the exudate and the establishment of drainage may mean full recovery of function. The wrist- and ankle-joint are particularly unfavorable for drainage. Some- times two large lateral incisions, 1 to l\ inches long, at the sides of the extensor tendons are sufficient; then again they do not insure drainage, and the question arises: To resect, and how far? The decision will depend more upon the experience of the individual and the severity of the case than upon any categorical paradigm. In the majority of cases of phlegmon or other inflammation involving the joint the incision as given and drainage — rather than packing — are sufficient. If pyaemic metastasis occurs, the patient sometimes succumbs to the effect of mul- tiple foci elsewhere, whether resection is done or not. The pathological processes in the joint are best overcome, if sufficient drainage cannot be obtained, by removing one or more carpal bones. One should be warned against total resection, especially with simultaneous removal of the lower ends of the bones of the forearm, unless the condition demands such imperatively. The result is usually discouraging if the infection is severe, even at the present time and in spite of drainage or packing. On the other hand, excessive conservatism in septic infection has its evil consequences. This applies particularly to delaying incision of 348 DISEASES OF THE WRIST AND HAND. the joint, for the anatomical relations are unfavorable for aspirating and injecting antiseptics, and the neglect will often be regretted if paid for by permanent ankylosis. It will be very unusual if sepsis of the wrist-joint cannot be controlled by the above measures and if ampu- tation of the forearm becomes necessary. After incising, the hand is slightly flexed, immobilized, and elevated, the patient being recumbent. Osteomyelitis of the radius may cause secondary effusion in the joint. The latter should be treated like the infectious exudations if aspiration of the joint has verified the character of the exudate — serous, flocculent, purulent — especially with reference to the bacteri- ology. The author has frequently found secondary effusions in the joint without bacteria, in osteomyelitis of the tibia and femur — as well as of the radius — and the further course justified the conservative treatment. After disposing of the primary osseous focus the effusion disappeared spontaneously without aid and without leaving fibrous ankylosis. If the osteomvelitic focus is in one of the carpals — a rare occurrence — the treatment should be that of osteomyelitis and the bone removed if neces- sary. The same applies to foci in the metacarpals or the phalanges; they are often complicated by septic arthritis of the adjacent joints. Chronic Inflammation of the Bones and Joints of the Hand. — Chronic inflammations of the bones and joints of the hand are most often met with in the form of chronic articular rheumatism, arthritis deformans, and gout (arthritis uratica). Frequent as is the occurrence of chronic articular rheumatism in the wrist, the metacarpophalangeal and interphalangeal joints, it rarely produces changes requiring surgical treatment. The multiplicity of the more or less painful inflammations of the joints, developing slowly with effusion, but without the doughy covering of the soft parts of tuberculous affections, will rarely be the cause of diagnostic error. Arthritis Deformans. — Deforming arthritis is distinguished by nod- ular thickening of the interphalangeal joints, by lateral — usually ulnar — and volar subluxation, chiefly in the wrist and metacarpophalangeal joints, and by the rapid loss of funcrion of the fingers, even to complete disability. Lateral displacement of the extensor tendons and secondary shortening of the corresponding muscles often combine to produce in a short space of time deformities of the hand and fingers that cannot be corrected. Although the greater number of patients are of advanced age, the changes in the joint may reach a severe grade in middle life, even at the twentieth year, almost always, however, in women. The surprising fact in the history, that there is often a rapid transition from full power of the hand during relative disuse, would indicate that at the beginning of the process renewed use of the hand would be more efficacious in preventing further changes than rest. Corrective treat- ment is out of question if ulnar adduction and volar subluxation are established. The initial stage belongs to internal medicine and saves further description. Gout. — Gout in the fingers more frequently leads to errors. Although the acute attacks are rarer here than in the toes, an acute swelling DISEASES OF THE JOINTS AND BONES OF THE HAND. 349 of the joint accompanied by intense pain and redness and without involvement of the lymphatics must be regarded as an acute attack of gout. The diagnosis is simplified as soon as the intra-articular and periarticular deposits of urates are recognizable on palpation by the sand-like grating, or if circumscribed yellow foci are evident in the inflamed skin, or if with the high-grade acute inflammatory swelling there is a more solid than fluctuating infiltration. The above-mentioned absence of the simultaneous signs of lymphadenitis which so frequently accompany phlegmonous, septic arthritis, the healthy appearance of the patient, and the points of the history, together with the local symp- toms, prevent error and wrong treatment. The incision of gouty nodules is only justifiable if there is a very great deposit of urates extending to the surface, or for the alleviation of pain. The discharge of urates and the indolent character of the secretion will certainly lead to the right diagnosis if it was previously wrong. Gout may produce high-grade deformities in the fingers and volar and ulnar deviation in the metacarpophalangeal joints. The value of exercise, massage, and hydrotherapy, in addition to internal medication, is generally recognized. For further details the reader is referred to the text-books on general medicine. Hereditary Syphilis. — The congenital luetic diseases of the bones and joints of the hand resemble tuberculosis clinically very closely. The diagnosis is simplified if syphilitic changes are found in other parts of the body: skull, nose, gums, anus, interdigital folds. In other cases the family history, observation of the course of the symptoms, and a tendency to retrogression without softening or perforation, are of diag- nostic importance. The individual foci on the metacarpals or phalanges may be so slightly distinguishable clinically from tuberculosis that the diagnosis must often be deferred for a time: in the joints the involvement chiefly of the periarticular tissues and the later evident involvement of the joint itself point to syphilis. The dactylitis syphilitica of Liicke, in the tertiary stage of syphilis, mentioned above under Chronic Diseases of the Skin, is more important. One or more joints are frequently involved and greatly distended but painless; the skin brownish- red ; the folds obliterated; the resistance usually exquisitely elastic. The disease is frequently confined to the capsule of the joint; exceptionally the cartilage, especially in the more central portion, is transformed into dense connective tissue, the chondritis syphilitica described by Virchow. Rarely there are hyperplastic changes in the cartilage and synovialis, or there may be softening, disintegration, and transformation of the focus into a condition similar to an abscess with the formation of fistulas. In the bones simple syphilitic periostitis is most frequent. There is a peculiar unilateral nodular formation similar to the "pseudotumeurs blanches" of the joint, or there are circular swellings without pain. If they are not recognized as syphilitic, on incising, the discharge of tenacious, clear, gelatinous masses reveals their specific nature; the bone may be intact. Large gummata are possible in the bone and medulla, although rare in the metacarpals and the fingers. These 350 DISEASES OF THE WRIST AND HAND. growths remain limited for some length of time unless complicated by infection from without. The gumma retrogrades spontaneously or it may involve an entire phalanx, the latter being completely absorbed. Treatment. — Conservative treatment, especially renewed inunctions, almost always brings recovery, as the patients are usually otherwise in excellent condition. Incision and cauterization are unnecessary. If the foci have perforated to the surface and are infected, the treatment is the same as for the other bones (skull, tibia). The necrotic masses, including large or small sequestra, are extirpated; the cavity packed and treated as a septic focus. Neuropathic Arthritis. — The arthropathy of nervous origin has recently claimed equally the interest of physicians and surgeons. Tabes dorsalis and syringomyelia are the chief causes. Following Mitchell in 1831, the pathological anatomy and clinical symptomatology of the disease have been especially studied by Charcot and v. Bruns. Interesting observations were reported by Czerny at the Surgical Congress in 1886, and studies were made by Karg under Thiersch. The part played by syringomyelia has been presented in a classical manner by Fr. Schultze. The nature and origin of neuropathic diseases of the joint are still obscure at the present time in spite of numerous hypotheses. The greater frequency of syringomyelia in males explains the prevalence of arthropathy in the same sex. The first symp- toms of the joint-involvement were recognized in 4 cases in v. Bruns' clinic at the thirty-ninth, thirty-seventh, seventeenth, and ninth year. In 51 joint-affections collected by E. Graf, trauma was frequently re- garded as the exciting cause; the subsequent swelling was usually pain- less. A certain amount of appreciable crepitus in the deforming joint was the first intimation to the patient of the disease. There is not necessarily any functional loss. The diminution or loss of temperature- sense is recognizable from the fact that fissures, wounds, inflammations, and burns occur without pain, to the amazement of the patient. (See affections of the skin in syringomyelia, page 337.) In spite of the manifold differences in the local symptoms the usually rapid onset of the deformity is characteristic. The enormous swell- ing of the articular surfaces, with or without moderate effusion in the joint, and the occasional periarticular swelling of the soft parts, are very striking; also the tumefaction of the capsule with irregular deposits of bone and the crepitation of the joint-surfaces which are partly de- nuded of cartilage. In the advanced stages the synovial sac may be so relaxed and dilated that very wide abnormal movement is possible, producing looseness and separation of the articular surfaces from each other and unusual subluxations. Thickening of the bone in some spots is accompanied by absorption in others. In the differential diagnosis the point given by v. Volkmann is valuable, namely, that whereas in the usual arthritis deformans the deforming process is limited to the joint, in neuropathic affections of central origin the extra-articular changes in and outside of the capsule are so dominant that they can scarcely escape the examiner. In spite of the great similarity of the anatomical TUBERCULOSIS OF THE JOINTS AND BONES OF THE HAND. 351 changes in the arthropathy of tabes and syringomyelia, the deformation is more rapid in tabes, as emphasized by Sokoloff. In regard to lepra mutilans, sec page 337. Acromegaly. —The differential diagnosis requires mention of acrome- galy, the disturbance in growth described by Friedreich as a hyper- ostosis of the entire skeleton, and by Fritzsche and Klebs as a non- congenital hypertrophy. The slow development of the disease is usually completed before the thirtieth year; the gradual enormous, paw-like growth of the hands (and feet) extends from the end-phalanges to the wrist (ankles), and is chiefly due to hypertrophy of the hone. The soft parts are not necessarily cedematous or glossy. There may he keloid growths on the extremities. The condition often affects only single ringers, and may thus present great difficulty in the differential diag- nosis from chronic inflammation of the bone or joint. In acromegaly, however, the joint is uninvolved. There are almost always pathological changes in the pituitary body and the procreative glands, sometimes in the thyroid and the pancreas, so that there was once a tendency to deduce the physiological connection of many of the blood-producing glands from the relationship of the symptoms of the presumably corre- sponding diseases: myxcedema, cretinism, Basedow's disease. For this reason v. Bruns has exhibited thyroidin in acromegaly, apparently with success. There is no surgical treatment. TUBERCULOSIS OF THE JOINTS AND BONES OF THE HAND. Tuberculosis of the Wrist-joint. — On superficial examination a fungous tuberculosis of the tendon-sheaths may be mistaken for dis- ease of the joint. The former may involve the joint synovialis and this secondary involvement then becomes relatively the most prominent. In children tuberculosis of the wrist is relatively infrequent compared to the same disease of the ankle; in middle and advanced life disease of the hand is more frequent. In the latter case it is often accompanied by numerous other tuberculous foci, especially in the lungs, or it is a local manifestation of acute, subacute, or chronic miliary tuberculosis. Symptoms. — The symptoms may vary greatly according to the severity of the attack: from a serous effusion or dry caries to circumscribed fun- gous growths or general tuberculous arthritis; from tenderness, limited to one of the bones, to tenderness of the infiltrated soft parts, spongy swelling of a spindle-shaped "white tumor" of the wrist, and the forma- tion of one or more fistulas; from the latter to secondary inoculation of the skin with the development of lupus or ulcerating tuberculosis of the skin about the fistula. In the history trauma plays an oft-repeated role. The localization, in the strict sense, is of great importance for the deter- mination of the clinical course and prognosis. This applies particularly to primary osseous tuberculosis of the radius. It may manifest itself as part of a diffuse, progressive tuberculosis of the shaft (rare); as a wedge-shaped focus in the epiphysis; as a rounded focus under the 352 DISEASES OF THE WRIST AND HAND. cartilage. Usually some time elapses before the radiocarpal joint is involved from the erosion of the cartilage; the mobility of the joint is fairly normal, the thickening and tenderness of the lower end of the radius pronounced, suppuration of the periosteum and involvement of the tendon-sheaths usually appearing at a later period. Resection gives excellent results. Primary tuberculosis of the base of the metacarpals is also usually circumscribed, the second and third being most frequently affected. Tuberculosis of the synovialis and of the carpal bones themselves represent the third group, in the strict sense, of tuberculous affections of the wrist-joint, disease of the synovialis apparently being more frequent. The disease is liable to involve the whole of or a larger part of the carpus, although one occasionally sees only one or more bones affected, especially in young patients, in whom recovery follows perforation, scraping, or partial resection. The disease here therefore gives a very bad prognosis not only as to function, but also as to life in not a few instances. It is often seen as the closing act of a tuberculous cachexia following phthisis; still even in such doubtful cases the author has not infrequently seen great improvement in general strength follow amputa- tion of the forearm. The " tuberculomas juxta-synoviaux" of the knee, described by Gangolphe, and of the wrist, reported by Sabatier, may be interpreted as a tuberculous bursitis or as a localized, circumscribed, tuberculous process connected with a protrusion of the synovialis or with the tendon-sheaths. Oilier reported a localized tuberculosis from a protrusion of the synovialis of the wrist. Diagnosis. — In addition to the history (heredity) and general condition (lungs) the diagnosis of tuberculosis of the wrist depends essentially upon the following points: slowly increasing effusion with gradual func- tional loss, rarely pronounced; pain in the bones, soon followed by more or less atrophy of the muscles of the forearm. If limited to a cir- cumscribed focus, there is localized tenderness. If diffuse, the picture is more and more that of a spindle-shaped "white swelling." The boggy oedema of the skin and the functional impairment of the tendons and fingers increase, the summit of the inflammation or threatening perforation being indicated by a reddish-blue color of the skin. If there are fistulas at the sides of the extensors, they show the typical tuberculous granulations, soft, oedematous, coated, and necrotic. The diagnosis is more difficult if the focus is localized or involves a portion of the joint. The differentiation from the synovial form is not infrequently dependent upon incision. Recently the .r-ray has made surprising revelations even where the disease was limited to one of the carpal bones. Treatment. — The treatment depends upon the age and general con- dition of the patient, and the location and extent of the disease. The prognosis often depends largely upon the general condition. Conser- vatism is as important in youth, especially in childhood, as it is counter- indicated in advanced life and by a generally weakened condition, for in the latter case amputation and not resection is to be considered. Statistics are useless in determining the demands of the individual case. TUBERCULOSIS OF THE JOINTS AND BONES OF THE 11 AND. 353 The proper decision is reached in each case by a sound objective analysis of all the chances under consideration. In the conservative treatment the chief points are immobilization of the joint and general hygiene (diet, care of the skin, air). The local measures stimulating the growth of connective tissue and attacking the tuberculous virus are: injection of antitubereulotis substances (iodoform emulsion, usually 20 per cent, iodoform-glycerin in doses of grains xv to oj of iodoform, injected immediately below the styloid process of the radius and ulna or at both sides of the extensor tendons) and Bier's passive congestion. The existence of a sequestrum counterindicates these methods. Aspiration and repeated injection of cold abscesses give excellent results, granting that the reactionary power of the organism is good (in childhood) or at least sufficient (in the absence of severe general symptoms). Osseous foci in children not infrequently heal spontane- ously even if there are fistulas; in middle life it is better to scrape them out thoroughly or perform an arthreetomy. Ankylosis and inflammatory subluxation (volar of the carpus) may recover satisfactorily under con- servative treatment, according to the extent of the process, or, on the other hand, require partial resection of the joint. Even if the surgery of the last decade has carried the operative treatment of tuberculous arthritis too far, nevertheless surgeons are indebted to Konig for having defined the operative procedure so clearly that it is applicable almost literally to the w r rist even at the present time. The principle of operative conservatism is perhaps carried too far by many to-day to the detriment of the patient. Fig. 220. Fig. 221. Spina ventosa of the first and third metacarpals. Spina ventosa of the first pha- lanx of the fourth finger. It must be admitted that the conditions are often very unfavorable for any plan of operation. The various anatomical paths through which tuberculosis can spread are a cross for the radical removal of all diseased Vol. III.— 23 354 DISEASES OF THE WRIST AND HAND. tissue and are the cause of recurrence. If, however, with the application of the Esmarch, all diseased tissue is removed, the operation is aseptic, and the entire after-treatment formed accordingly, one will have the satisfaction of seeing how recovery can follow shrinkage of the exuberant granulations of the large synovial pockets of the carpus. If possible, resection should be limited to the carpus and the healthy bones of the forearm left intact. That is the experience of Konig and many others who treat accordingly. Fig. 222. Tuberculosis of the second phalanx of the index finger (healed). Ankylosis of the interphalan- geal joints and shortening of the third and fourth fingers due to lupus, (v. Bruna.) Tuberculosis of the Metacarpals and Fingers. — In childhood and youth tuberculosis most frequently affects the bones, in middle and advanced life the joints, of the hand and fingers. Spina ventosa is a term that has been applied for a long while (Wind- dorn) to a characteristic form of tuberculosis of the bones. It often begins at the epiphyseal end of the shaft, spreads in a relatively short time through the entire medulla, infiltrates the spongiosa, and replaces it by boggy, purulent, granulation-tissue containing the sequestrated remnants of the spongiosa. The thin cortex and periosteum are distended by the increasing inflammatory products; here and there the periosteum reacts and forms new bone, so that soon the finger looks as if the bone had been "blown up." The result of the process is well shown by the x-ray. The disease is not infrequently found simultaneously in several phalanges or metacarpals in the same hand. (Fig. 220.) TUBERCULOSIS OF THE JOINTS AND BONES OF THE HAND. 355 Symptoms. — The cylindrical swelling of the bone is evidenced by a painless (edematous swelling of the soft parts soon followed by redness in spots or all over the area involved. The function of the tendons is at first normal, later impaired only by the swelling. 'The parts feel elastic and may later show softening and fluctuation. In the meta- carpals the lesion may be mistaken for a tendon-sheath affection. The picture is otherwise so characteristic that it can only be mistaken for a congenital or tertiary syphilitic lesion. Treatment.— In the early stages the treatment is limited to general measures of hygiene and diet; locally to immobilization. .Many cases of spina ventosa recover fully under this treatment. If the softening Fig. '22\\. Arretted growth of the middle finger following spina ventosa of the first phalanx in the third year of life. of the bone extends rapidly and fluctuating abscesses threaten to per- forate, the diseased medulla should be removed. To avoid the tendons and nerves, the incision is made laterally (on the metacarpus, naturally on the dorsum). All diseased tissue is carefully removed with a sharp spoon and the wound then treated in general principles. The result leaves much to be desired from an aesthetic point of view in all cases of extensive involvement, whether in the metacarpus or phalanx. Fre- quently high-grade disturbances of growth of the finger follow, almost comparable to total defect. (Fig. 223.) In this case one finds remnants of an epiphysis, or of the shaft attached to the next joint, and in between, fibrous tissue without new bone. (Fig. 222.) If there are several such 356 DISEASES OF THE WRIST AND HAND. changes in the metacarpals and the phalanges in the same hand, the deformity may be very striking, although the functional impairment in the use of the fingers may be relatively slight. Tuberculosis of the Metacarpophalangeal Joint. — Tuberculosis of the metacarpophalangeal joint either starts from a spina yentosa and extends along the adjacent bones (in children) or occurs primarily in the synovialis fin old age). Symptoms. — At the onset the characteristic spindle-shaped swelling and a serous or slightly cloudy effusion are the dominant features. Later the external symptoms of inflammation are usually spread more diffusely over the adjacent parts, or the case may first be seen with pro- nounced destruction of the joint. In the milder form there is slight crepitus and the bones are moderately displaceable upon each other; in the severe form there are pronounced displacement of the adjacent bony surfaces, lateral inflexion, and loosening of the ligaments. The distal phalanges may pendulate at the diseased joints, and, if chronic, there may be perforation, fistulas, and sequestra. Prognosis. — The chances of recovery without operation are as unfa- vorable in these small joints as they are in tuberculous affections of the joint in middle and advanced life. Treatment. — Usually it is not difficult to decide between arthreetomy, resection, and amputation. Very often the disease is accompanied by an advanced pulmonary tuberculosis. CONTRACTURES, 1 ANKYLOSIS, AND DEFORMITIES OF THE HAND. On practical grounds it is advisable to consider contractures and ankylosis together. The paralytic and neuropathic forms of contrac- ture were discussed in the section on the Upper Arm and Forearm, because the source lay outside of the hand, and because they are more often the results of affections and lesions at a higher level. The de- formities in lupus causing contractures were discussed under Tuber- culosis of the Skin. Helferich was the first to call attention to con- genital interphalangeal ankylosis of the thumb in ossifying myositis. It was found in almost three-fourths of the cases examined for that purpose. Dermatogenic and tendogenic contractures are important on account of their e very-day occurrence and unfortunate functional and aesthetic consequences. Dermatogenic Contractures. — Congenital contracture is most fre- quently ^fen producing flexion of the little finger at the first interpha- langeal joint. The skin on the volar side is too short to allow complete extension; motion is free in the joints. Flexion of several fingers, the second to the fifth, has also been reported repeatedly. In all of these 1 The propriety of u-ing the English equivalents of the author's dermntorjene, lendngene, etc.. in connection with 'he pathogene-i- of contracture- seems obvious in view of the fact that myogenic, myogenous, and neurogenous are accepted in the nomenclature in precisely the same sen.-e. CONTRACTURES, ANKYLOSIS AND DEFORMITIES OF WAND. 357 forms the cause is to be found in a primary maldevelopmenl of the volar skin. The methods of 1'. Vbgt and llolfa represent the fundamental forms of non-operative treatment of such contractures; slight modifications may be made. Vbgt connects two broad rings of thin sheet metal (Fig. 221!, for the first and middle phalanges, by means of a volar strip hinged at the level of the joint; extension is made by means of an elastic hand stretched between the rings on the extensor surface. Hoffa's apparatus consists of a springy, well-padded dorsal splint fastened to the finger by strips of adhesive plaster after extend- ing the finger as much as possible. If the strip is not Fig. 224. elastic it is not well home if applied with force, and is useless if the finger is not extended. The skin may be incised by a V-shaped incision, the finger stretched, and the edges then sutured Y-shaped. Treatment. — Traumatic contractures following tears, laceration, inflammatory destruction of the tissues, or burns, are all to he regarded and treated from the same point of view. The surgeon's first task should be to prevent their development as much •1 1 rni ii" i-i 1 t.xtension splint for as possiole. the prophylaxis can accomplish much; contrac t U re of the fin- for example, by applying the dressings so as to coun- ger. (Vogt.) teract the impending contracture. If the desired result is not obtained in this way, active massage may be tried or finally incision, transverse and longitudinal, of the contracted parts, and graft- ing to prevent secondary changes in the joint. If the treatment is not effectual or the contractures come under obser- vation entirely untreated, the surgeon often has before him severe hyper- flexion and extension attitudes, not infrequently with abduction, particu- larly after burns. The functional hindrance is caused by a varying number of fibrous bands and cicatricial nodules, covered by fragile, scaly, friable epidermis, and which maintain a cartilaginous firmness in spite of massage. The hindrance is also due to the great pain caused by the attempts at stretching. The disuse of the joint, the increased pressure on one side and decreased pressure on the other cause corre- sponding atrophy and growths in the occasionally subluxated joint- surfaces. In many cases, especially if of short duration, massage and gradual manual and mechanical stretching may have some effect. The exten- sibility of new cicatricial tissue, which sometimes leads to annoying changes, is here a useful quality. W. Busch has called attention to its therapeutic utility. In order to preserve the pliability of the skin it is kept constantly greased where it is to be stretched. It should be kneaded and stretched daily for about ten minutes, the result tested by subsequent passive movements, and the parts then held in the position attained if it does not discomfort the patient too much. At night the parts are immobilized in a spring splint such as was described above for congenital contracture. Too much, however, must not be expected 358 DISEASES OF THE WRIST AJSD HAND. from these manipulations, particularly if the cicatrix is old and the patient advanced in years. In any event they are always a test of the endurance of the surgeon and patient. Of the large number of apparatus constructed and recommended, tho.-^e of Delacroix, Eulenburg, Nyrop, Matthieu, and Schonborn have enjoyed the greatest approval. The one of Schonborn Fig. '!-'< serves as a model for general use; a leather sheath like a glove {A I supports a metal dorsal splint (B B) and rear-lies to the distal third of the first phalanx of the finger or finders involved; it is connected at this point by two lateral hinge-joints to a metal gutter-splint I): this gutter is pulled toward the dorsal splint by elastic bands and so exerts traction on the contracture. Stretching by a suspended weight deserves trial. In the medico-mechanical institutes Krukenberg's or similar apparatus is used. Fig. 225. Schonborn's correcting splint for contracture of the finger. In many, in fact in all, severe and extensive cases, especially those due to burns, these measures do not accomplish tlif j desired result even after long use. This applies particularly to old cicatrices. In operat- ing it is advisable not to limit one's self to one method. In some cases an oblique incision and shifting the edges upon each other are successful ; in others a V-incision, or excision and Thiersch grafts, or pedunculated or whole-skin flaps. Whatever method is used, the essential is to prevent the return of the contracture by overstretching, applying an excess . I Shortening of the muscles ( myogenic contracture) by retracting the tendons naturally causes contracture of the fingers. Besides resulting from central and peripheral nerve affections, the condition may also follow prolonged immobilization of the arm and hand. The action of the flexors soon predominates and leads more and more to a flexion contracture. The highest grade follows ischemic degeneration of the muscles, as pro- duced by constricting dressings. (See page 317.) In the latter case sur- gical treatment is almost powerless. The myogenic contractures due to immobilization are overcome in weeks or months by use, massage, exer- cises, electricity, and baths. So the prophylaxis is of first importance: to guard against protracted immobilization in splints. The contrac- tures due to suppuration and cicatricial contraction of the muscles occa- sionally yield only to tenotomy, or, better, remain a noli mc tangere against further treatment. Arthrogenic Contractures. — Two main varieties may be distin- guished: those in which the hindrance is in the joint, fibrous or bony ankylosis or shrinkage of the capsule; and those in which the hindrance is extra -articular. Accurately speaking, only the former are purely arthro- genic. As mentioned, they are usually the result of acute and chronic inflammations, pyogenic or otherwise infectious. The ankylosis is <\ue to 360 DISEASES OF THE WRIST AND HAND. alterations in the cartilage following protracted changes in the circula- tion, and on account of the slight tendency of the cartilage to regener- ate, the contractures occasioned by such ankylosis — which ankylosis is more essentially a contracture, although termed ankylosis — are only amenable to resection or exarticulation. Massage and passive motion are useless. Not infrequently as the result of failure to recognize the anatomical condition, severe pain is added to the injury by employing forced movements. The author cannot suppress the fact that this happens repeatedly in medico-mechanical institutes. Treatment In- passive movements and massage are only indicated when the apparent ankylosis of the joint is due exclusively to shrinkage of the capsule. The same applies to the class of so-called arthrogenic contractures which are due to periarticular adhesions of the tendons and adhesions along the tendons. Incision is rarely necessary, and recovery is usually effected within a few weeks by massage and movements. Lateral displacement of the tendons should be mentioned in connection with arthrogenic contractures, as it is not infrequently associated with deforming arthritis and acts as an extra-articular cause of contracture. Described by Charcot, its mechanism and treatment were first carefully studied by Krukenberg. The hand is adducted and presents a flexion contracture in the metacarpophalangeal joints, greatest in the fifth, less in the fourth, third, and second, the thumb being uninvolved. The fingers may be extended in the other — interphalangeal — joints and pro- duce a rather characteristic deformity. On palpation the metacarpal heads of the contracted fingers are prominent and the extensor tendons are displaced to the ulnar side of the shallow dorsal groove on the head of the metacarpals. It appears doubtful whether one may expect to be successful in following Krukenberg's proposal to replace the tendons by chiselling out the old groove or making a new one on the head of the metacarpal. So far the author has hesitated to try it. Spastic Contractures. — The spastic contractures of the fingers, although they do not belong in the strict sense among contractures, are best introduced at this point. They occur as occupational diseases in individuals who do uninterrupted, exacting work with the fingers for many hours each day: writers, pianists, violinists. The most fre- quent of these co-ordinated occupation-neuroses is "writers' cramp." Its clinical picture varies according as the paralytic or pronounced spastic symptoms predominate. Benedict very aptly divides them into paralytic, spastic, and convulsive. In the first of these there is chiefly a rapidly increasing tired feeling in the arm and hand. In the second there are tonic and clonic spasms, especially spastic contraction of the thumb against the palm. In the third there is a tremor beginning with the writing and by its gradual increase preventing the necessary co- ordinated movements. In these occupation-neuroses the cramp begins as soon as the special work is attempted, whereas it often remains absent in other similar complicated actions. This would indicate that the treatment should begin with temporary or complete interruption of the work. Unfortunately, however, there is a large number of cases COSTllACTrilES, ANKYLOSIS AND DEFORMITIES OF HAND. 36] in which it returns just as soon as the old occupation is resumed. The prognosis is therefore generally to be given as unfavorable. Treatment. — The treatment consists chiefly in strengthening or rest- ing the muscles involved in the cramp and applying massage over the muscles and their corresponding nerves. It is profitable to stroke with varying duration and intensity the muscles of the mid-hand (lumbricales and interossei), those of the forearm, upper arm, and shoulder; the cervical and brachial plexus, the ulnar, radial, and median nerves, stroking the muscles upward, the nerves downward. Galvanism is best applied with the positive pole at the neck and the negative pole in the supraclavicular fossa or at selected points along the nerves of the arm. The application should be increased from two gradually up to six or eight minutes. After several months there may be improvement, in mild cases recovery. In every case there is the danger of recurrence on resuming the former injurious occupation. Many apparatus exist devised for the purpose of "cutting-out" the affected muscles. Accord- ingly they "harness" the hand to a certain extent and spare the fingers from the combined action of the individual muscles and simplify the movements by shifting them to the wrist. Nussbaum's well-known bracelet usually tires the hand very much in the long run. To the author's mind the same applies to Zabludowsky's small apparatus. It is well to try various apparatus on the same patient. Dupuytren's Contracture of the Fingers.— Surgeons are indebted to Dupuytren for the first accurate anatomical description of contraction of the palmar fascia. In opposition to Boyer and Cooper, he showed that the characteristic cord-like contraction of the finger was due to gradual shortening of the palmar aponeurosis. New fibrous tissue and shrinkage predominate in the microscopical picture. The new-forma- tion is doubtless of an inflammatory nature and appears in spots. Nuclear proliferation takes place in the sheaths of the arteries as well as in the connective tissue between the individual fibrous bands. This nuclear proliferation is beautifully shown in the fibres attached to the skin. (Langhans.) The contracture attitude of the fingers is caused by the shrinkage of the bands of the palmar aponeurosis running to the fingers and merging into the tendon-sheaths at both sides of each finger. The aponeurosis also sends compact fibres into the subcutis. On expos- ing the radiations of the aponeurosis in the fingers the author frequently finds considerable growth, similar to a fibroma, palpable beneath the skin as circumscribed nodules. The cause of origin of these changes is the irritation of the tissues produced by hard work and trauma; the coexistence of arthritis and contraction of the palmar aponeurosis has been noted at various times. (Konig, Liicke.) Many authors regard the disappearance of the fat- cushion in advanced age as predisposing. Recently the etiology of the contracture has again been actively discussed. Ledderhose, from clinical observation and microscopical study, is convinced that the beginning of the disease is an inflammatory proliferative process in the cells and vessels of the aponeurosis, a "fasciitis," and that later trauma produces 362 DISEASES OF THE WRIST AND HAND. lesions in the inflamed and changed fascia and leads to the formation of nodules, and through these to retraction of the tissues. Janssen completely excludes the causal significance of trauma. Neutra seems to have gotten especially far away from an objective view in con- necting the contraction with diseases of the central nervous system. The author has never seen the disease in females, and it has never been seen in children. In 2 of the author's cases, father and son, the father had the maximal contracture position; the son, a lawyer, thirty-three years old, had a unilateral deformity. Fig. 226. Fig. 227. Different stages of- Dupuytren's contracture of the fingers. The affection usually begins at the metacarpophalangeal joint of the fifth or fourth finger, or somewhat more distally; then attacks the third finger, the thumb, and leaves the index finger free the longest. Generally one or two years pass after the appearance of the first nodular thickening before the contracture begins, and in six, ten, or twelve years it has reached a high grade, the highest being when the finger-nails cut into the palm. At the onset it is usually painless. Flexion is unimpaired, whereas extension beyond the contracture position is painful and well- nigh impossible. The diagnosis is simple. The characteristic localiza- tion, together with the pronounced formation of nodules or bands without cicatricial changes in the skin, and the lack of inflammatory symptoms, are easily interpreted. CONTRACTURES, A\KYL0SIS AND DEFORMITIES OF BAND, ;;<;;; Treatment. — At the onset treatment by apparatus, massage, and baths may check the process. In advanced cases operation is Indicated, namely, thorough excision of the diseased parts of the aponeurosis. The author advises excision even at the outset, as it can he performed without harm if aseptic, insures the quickest result, and if there is a good, yield- ing cicatrix without any loss of skin, brings recovery. The author makes the incision entirely from an anatomical point of view and dependent upon the extent of the disease; in every case he makes a large palmar flap with a lateral base. Lotheissen has published an article on a similar incision. Lexer recommends even for milder cases that in addition to removing the entire aponeurosis large portions of skin or the entire palmar skin should he sacrificed, and covers the wound with a whole- skin flap, a more extensive operation. The results are designated as good "in every case in proportion to the extent of the operation." Older operations are omitted because they take our present knowledge of the pathology only partially into account. Snapping Finger. — In describing contractures, u snapping finger" (Trigger finger, Schnellender finger, doigt a ressort) should be consid- ered, the etiology of which has not been cleared up in every ease. The peculiarity of the affection is that in flexing and extending the finger, occasionally only during one of these movements, there is a sudden cheeking, ahvays at the same point, usually with a slightly painful jerk. The patients then have to exert some force to free the finger; sometimes they have to loosen it with the other hand; its liberation may also be accompanied by a snap. Since the first report made by Notta, in 1850, the affection has con- stantly claimed the attention of surgeons, and numerous hypotheses have been advanced as to its pathogenesis. Schonborn's operations and various autopsies threw the first light upon the subject. Robel collected 161 cases for the author, only a few of which did not involve the fingers; 41 were in the thumb, and of these 28 in the right; 12 in the index finger, of these 11 in the right; 47 in the middle finger, of these 34 in the right; 44 in the ring finger, of these 21 in the right; 10 in the little finger with 5 in the right. The sexes were equally represented. In 131 cases, 93 were given as the result of trauma or overwork. In addition to experimental investigations of Menzel, A. Schmitt, Poirier, and others; there have been so far 26 examinations made on operation or autopsy Lannelongue found a tumor, bean-size, of the tendon-sheath over the base of the first phalanx of the afTected finger. Leisrinck found a hernial protrusion of synovial membrane. Wiesinger found that a tender nodule was due to a yellowish thickening of the tendon, h inch long, which caught in the sheath, and was released with a snap. Sehon- born reports a transverse band over the flexor tendon at the first inter- phalangeal joint of the middle finger, and on incising exposed a trans- verse fibrous band passing over both tendons, which at this point had no sheath. There was also a fibrinous deposit on the flexor sublimis tendon. In a boy two and one-half years old, Sick saw the affection develop within eight weeks after a puncture- wound ; the operation 364 DISEASES OF THE WRIST AND HAND. showed that puncture had nicked off a tab of the tendon which turned back and caught, during flexion, in the sheath. Duplay found an annular fibrous thickening of the tendon sheath; v. Heineke found a simi- lar thickening due to previous inflammation. The author's second case admitted of no other interpretation. The findings on autopsy reported by Necker from v. Brims' clinic, in the case of a woman fifty-two years old, with the affection in both middle fingers at the first interphalangeal joints, are especially interesting: In the right finger there was a hard spindle-shaped thickening of the tendon, f inch long and double the width of the tendon, just below the forking of the flexor sublimis; the palmar surface of the swelling was arched, the dorsal surface, lying upon the profundus tendon, flat; on dividing the sublimis tendons below and exposing the profundus tendon a similar thickening was found arched in opposite direction. The condition was the same in the left finger. Microscopically the fasciculi of the tendons were found separated by undulating hypertrophied connective tissue, here and there containing bloodvessels, the fibrils being thicker and more compactly arranged than in normal interfascicular connective tissue. Baumgarten regarded the- process as a simple hypertrophy of connective tissue. Similar microscopical conditions were found in the author's first traumatic case operated on, and reported in detail in Robel's inaugural dissertation. In fourteen cases in soldiers (Schulte) the affection was referred to rifle drill at the beginning of service. In all cases it began with stiffness, and thickening of the flexor tendon was demonstrable at an early period; the "snapping" took place only during extension. Nelaton regarded thickening of the synovial membrane of the joint as the principal cause; Menzel, and with him Hyrtl, Berger, Vogt, Fieber, Felicki, believe that it is caused by a nodular thickening of the tendon and simultaneous con- striction of the sheath. The single instances which showed no analogous condition, especially those explained by the theory of abnormally high tension and sudden relaxation of the ligaments (Poirier), displacement of the ligamentous insertions (Steinthal), enlargement of the transverse articular ridges or lateral protuberances from the articular head (Konig, Vogt), and finally those explained by Carlier's theory of nervous dis- position and reflex spasm of the flexors — all these are individual observa- tions which cannot be classified with the great majority of cases. Based on the fact that most of the operations and autopsies supported Menzel's original theory, the author is inclined to the view that the snapping is chiefly caused by a "tendinitis callosa circumscripta" or "nodosa hyper- plastica," often traumatic. Perhaps Ziegler's view is correct, that the swelling of the tendon is due to the irritation of urate deposits, for Bar- low, Relm, Troisier, and others have also mentioned rheumatic nodules in this connection. There is little accurate microscopical evidence for regarding the thickening as a genuine fibroma. Vogt claimed that an interstitial extravasation of blood in the tendon might be significant etiologically. Certainly a small chondrosarcoma (Schmitt) or tuberculosis or gumma are rare causes. TUMORS OF THE HAND AND FINGERS. ;;<;;, Treatment. — In recent cases massage may occasionally be successful (Schulte); in old eases its efficacy is improbable. For the latter, opera- tion offers the best prospects, the extent of the attack depending on the condition found. Operation is almost always followed by recovery. In the author's cases it was demonstrated as permanent at the end of a year. TUMORS OF THE HAND AND FINGERS. Ganglion. — Ganglion is described here partly on clinical and prac- tical, partly on etiological grounds. Following the earlier investigations of Gosselin, in 1852, and of Teichmann, in 1856, it was customary to regard the small cysts found about the wrist containing a gelatinous substance and covered with a dense fibrous sheath as protrusions— diverticula — of the synovialis of the joint, the pedicle of which com- municating with the joint having become obliterated by adhesive inflam- matory processes so that they became closed off and appeared as inde- pendent cysts near the joint. Ganglion thus came to be regarded as a retention-cyst in which the collected synovial fluid thickened and became gelatinous, v. Volkmann sided with this explanation, but for the origin of the form of ganglion known as colloid cyst of the joint admitted the explanation given by Virchow, namely, that originally small multi- locular cysts were formed out of small spaces in the loose cellular tissue about the tendons, and later developed into a ganglion through dis- appearance of the individual dividing septa. Based upon his operations, Riedel defined the pathogenesis more sharply: on excising a ganglion broadly attached to the capsule of the joint, if the dissection is done carefully, the capsule often shows a defect before the ganglion is opened. This shows that only a very thin septum exists between the ganglion and the cavity of the joint. Where the pedicle was very short, on cutting it off, gelatinous material came from the ganglion and synovial fluid from the joint. It follows that the ganglion can be produced only within the substance of the joint-capsule. These considerations of Riedel have been fully confirmed by the studies of Ledderhose, and his in turn by other authors. Accordingly, in ganglion the surgeon is supposed to have before him a "cystoma" resulting from colloid degeneration of the connective tissue. If these changes in the connective tissue occur at several adjacent points, the ganglia formed are multilocular; the septa between the various compart- ments disappear gradually and form the unilocular ganglion. According to this, the significance of the contents as products of exudation and the conception of retention cysts would be invalid. Payr places their trau- matic origin in the foregound and regards them as traumatic inflamma- tory softening cysts. Konig maintains that the ganglia " are related to the capsule." He agrees with Falkson that the ganglia are usually adherent to the tendon-sheaths, but that the tumors extended to the capsule in all cases and had to be dissected off, so that their origin from the capsule is more likely, the adhesion to the tendon-sheaths being secondary. 366 DISEASES <>F THE WRIST AND HAND. On the hand, the ganglion is found chiefly on the radial side of the back of the wrist-joint, especially between the tendons of the exti indicis and the extensor carpi radialis. Much less frequently it lies to the volar ,-ide of the epiphysis of the radius and causes severe func- tional disturbance, according to Konig especially in pianists. Maison- neuve, Verneuil. and Witzel have reported small, hard cysts covered with endothelium attached to the capsule or the periosteum and situated upon the flexors in the palm — metacarpophalangeal joint — or upon the flexor surface of the first phalanges, and causing neuralgia in the nerves of the fingers by their pressure. Ganglioo is seen more frequently in women than in men. and is more common in youth. The form of the typical ganglion upon the dorsum is usually spherical, sionally tabulated, the upper surface smooth, the contents fluctu- ating. The tumor becomes flattened when the wrist is flexed; the dense lie appears to relax and previously uncertain fluctuation becomes distinct. It rarely attains to greater -ize than that of a hazelnut. It.-, mobility is often evident. The functional disturbance is usually slight. Hysterical _ onetimes complain of a weakening sensation caused by it. Traumatic origin, though often stated, is rarely credible and is illy absent. Treatment. — In view of the infection of the tendon-sheaths or joint expected at an earlier period, the treatment had every reason to be hesitating. The contents of the sac were usuallv crushed foreiblv with the thumb or by a blow of a hammer, or liberated by subcutaneous discission with an instrument similar to a tenotome. The results of all these methods are very uncertain, recurrence usually follows. Aspi- ration of the contents and injection of iodine are equally uncertain. Splitting the ganglion and packing under aseptic precautions gives better results, the packing if continued long enough producing obliter- ation of the sac. Extirpation, however, is the most certain method and the one most used at the present time, but requires careful asepsis. With the aid of the Esmarch it is easily accomplished: if large openings are made into the joint, they are closed with from one to three buried silk sutures; -light injuries of the tendon-sheaths may be ignored. The skin suture should be exact. Recovery follows in from five to - inder an aseptic dres-ing upon a hand splint. I >: :he genuine tumors of the hand the first to be considered are warts, naevi, angioma, epithelial cysts, and the rare lipoma of the skin. The hand is a -pot of predilection for enchondroma: osteoma is sup to be more rare. Of the malignant tumors the author will consider ima of the fascia, tendon-sheaths, periosteum, or bone, and epithelial carcinoma. According to the careful compilation of hi- assistant. Dr. Holler, of the 36 tumors of the hand and fingers occurring among 36,144 patients in the author's polyclinic, there were 10 fibromata. 7 -arcomata. 7 epithelial cysts, ■"> angiomata, 4 carcinomata. 2 o>teomata, 1 neuroma, no enchondromata. Naevi, papilloma, and ganglia are omitted. Al>o from the statistics of Guilt and R. Miiller the frequency TUMORS OF THE 11AM) AM) FINGERS. 367 of genuine sarcoma is remarkable compared to the statistics from other places (in ( iennany ). This is explained by the fact that in v. Bergmann's clinic and the author's institute, even the smallest tumors in the earliest stage of development were subjected to microscopical examination. Warts. — It is a fact of experience current among the non-medical that warts can be inoculated from one site to another. The surgeon will be surprised to find that immediate recurrence can take place under his own observation after excision. Jadassohn and Lanz have demonstrated by experiment that it can be transmitted (to be sure, only in the same individual!). The existence of warts on the unprotected parts of the hand point to the significance of external injuries. They are more frequent in children, often increase rapidly from mechanical insults, suppurate if injured, and are very annoying especially if on the flexor surface of the hand and fingers; sometimes they grow to the size of a hazelnut, and are then very disfiguring. Occasionally they go as they come, spontaneously. Treatment. — Ligation is often followed by recovery, often by in- creased recurrence. They may all disappear on the application of nitric- acid or chromic acid, or they may resist the acid entirely. Radical excision usually insures freedom from recurrence, but, as mentioned, not always. Naevus pigmentosus (pigmentary mole), without or with hair (nsevus pilostis), on the hand or fingers is rarely larger than a pea or bean. Those covering an entire finger or the back of the hand belong to the greatest rarities. Hemangioma, Telangiectasis, Cavernoma. — These vascular tumors not infrequently appear on the hand and fingers, circumscribed or diffuse. On superficial examination small, circumscribed angiomata may be mistaken for warts, but the pure epidermoid covering with no evidence of epithelial growth and the characteristic color of the vessels are sufficiently clear signs. If ulcerated, such angiomata may resemble granulomata; usually, however, the history gives sufficient evidence of the original character of the "granuloma." Cavernous tumors commonly start in the subcutaneous veins, appear bluish through the skin, and on palpation are felt as bulbous or berry- like masses and are compressible. They are often multiple. Telangiectases occur almost exclusively on the back and sides of the hand and fingers. The author usually found them associated with other congenital growths and anomalies of the vessels: lymphangioma, circumscribed or diffuse fat-hypertrophy, and growths similar to elephan- tiasis (once a diffuse cystic degeneration of the sweat-glands). J. Bell reports the occurrence on the upper extremity of an "aneurisma per anastomoses" — the aneurisma racemosum of Virchow, the tumeur cirsoide of Robin, the phlebarteriectasia of O. Weber — the prognosis of which is so unfavorable. Krause subjected a case of Stromeyer to careful study: the disease was characterized by sacculated protrusions of the arteries and veins, involving chiefly the finer branches; the veins and arteries enter directly into each other accompanied by many changes 3(38 DISEASES OF THE WRIST AND HAND. in the intervening capillaries. The danger of rupture indicates multiple ligation, or, still better, amputation. These vascular tumors, most of which are supposed to be of traumatic origin (v. Bramann), are characterized by a rhythmic, humming murmur transmitted downward (v. Bramann), which was only absent in Wolff's case. In one of Nicoladoni's cases there were two small, discrete, pulsating venous sacs on the dorsum of the hand, the entire venous system of the arm and hand being markedly ectatic. The venous pul- sation could be seen and felt in the case of cirsoid aneurism of the hand reported by Hoffmann, as well as in the case of Widenmann in v. Brims' clinic, in which there was an accompanying contracture of the fingers and oedema of the hand due to the tumor. In the latter case, seven days after ligation of the brachial amputation of the arm was necessary. The specimen showed an abnormal communication between the inter- osseous artery of the forearm and a deep branch of the cephalic vein. Cirsoid aneurism (arterial cirsoid aneurism, arterielles Rankenan- giom, arterial cirrous-angioma ), a genuine vascular tumor consisting of a more or less circumscribed dilatation of a vascular area extending to the capillaries, is described by Heine. Wagner states that 88 per cent of all cirsoid aneurisms are congenital and develop from telangiectasis, as demonstrated by Heine, Korte, and Schtick with reasonable certainty in the case of those of the head, while only 12 per cent, are of traumatic origin. Telangiectasis develops chiefly in the capillaries, whereas cirsoid anetirism develops in the arterias. Wagner found 16 cases in the literature. Treatment. — If operable, the aneurism should be excised. On Thiersch's recommendation Schwalbe's alcohol injection has been used repeatedly with success: rqvj-viij of 40 to 80 per cent, alcohol every two or three days. Lipoma. — Lipoma of the hand or fingers is comparatively rare. It occurs either as a diffuse growth of the cutaneous adipose tissue (see section on Congenital Hypertrophy) or circumscribed. It develops from small fat-nodules. Diagnosis. — The diagnosis is sometimes difficult. It has often been mistaken for hygroma (Boinet), ganglion, and even enchondroma. A pseudofluctuation and fine crepitus occasionally found in lipoma are par- ticularly liable to misinterpretation, v. Volkmann observed transparency in a lipoma of the hand. The peculiar direction of the growth is of great diagnostic value; whereas the purse-form hygroma, corresponding to the common volar tendon-sheath, develops upward beneath the trans- verse carpal — annular — ligament, lipoma never oversteps the boundary set by the dense ligament, but rather develops along the metacarpals toward the fingers, and may even force the metacarpals apart eases of Perassi, Bryant, Hodges, Wahl) and appear on the dorsum. In the fingers it is almost always located on the volar surface. Lipoma on the dorsum can be mistaken only by a very cursory examination. Lipoma arborescens of the tendon-sheaths was first described by Sprengel. By reason of its great rarity and the similarity of the symp- TUMORS OF THE HAND AND fingers. 369 toms it is easily mistaken for villifonn fungus — tuberculous — and is lirst recognized upon incising. Treatment. — The removal of large palmar lipomata is usually simple. In a boy four years old Ktister excised a lipoma which extended from the ulnar border of the little finger to the elbow. Fibroma. — Genuine fibroma of the skin of the hand and fingers belongs to the rarities. Its site of origin is more frequently the palmar fascia, its radiations extending to the fingers, the tendon-sheaths and tendons, and occasionally the joints and periosteum. Callus of the ten- doncaused byinjuries, overstretching, and laceration is to be classified with fibroma; if the ensuing proliferation of the interfibrillar tissue of the ten- dons exceeds the physiological amount of cicatrization and involves the tendon-cells, the callous masses appear as firm spindle-shaped tumors along the tendon. (See also Snapping Finger.) The first symptom of Dupuytren's contraction of the palmar aponeurosis may he single or multiple small fibromata in the palm. Certainly not a few of the fibromata of the hand and fingers are due to trauma. Their greater frequency on the flexor surface of the finger than on the extensor surface speaks for this. Heller reports the ratio of volar to dorsal fibromata in the patients at the author's polyclinic as 13 is to 3. Diagnosis. — Fibromata of the skin are firmly attached to the latter, easily movable on the underlying parts, those of the tendon-sheaths being movable chiefly in the transverse direction, while those of the tendons follow the movements of the latter. Even the larger fibromata of the tendon-sheaths do not usually become adherent to the underlying bone. Treatment. — Fibromata should be removed as soon as they cause functional disturbance, which happens early- if the tendon-sheaths or tendons are the seat of the growth. Sebaceous Cysts. — Atheroma occurs on the dorsum, but never in the palm. The epidermal cysts observed in the palm (cyst epidermique, tumeur perle, dermoide, cyste sebacee) are to be regarded for the greater part as of traumatic origin. (Reverdin, Le Fort, Garre, and others.) Their interpretation is still within the bounds of discussion. Franke, who thinks they should be termed epidermoids, admits the traumatic origin only in a slight percentage. Based upon his own experience and observation as carefully verified by the history and microscope, and upon the view of Reverdin and Garre, the author would like to indicate the etiological significance of trauma. Clinically the epithelial cysts in question are very similar to sebaceous cysts, vary in size from that of a millet-seed to that of a hazelnut, have a smooth, rounded surface, feel of cartilaginous hardness, and are tensely elastic or distinctly fluctuating. The skin is movable over the tumor; or if the tumor is large, is tense, fissured, callous, and scaly, and sometimes shows macroscopical cicatricial changes. Their develop- ment not infrequently extends over months and years. They occur almost without exception in men, have never been seen in children, rarely in women. The index finger is most often affected, sometimes Vol. Ill— 24 370 DISEASES OF THE WRIST AND HAND. the volar surface of the other fingers, rarely the palm. All of the author's 3 cases were of the right hand, 2 in the palm. The growth is preceded by incised or puncture-wounds, bites, or tears. Kummer found such an epithelial cyst formed about a foreign body (needle-point). Its occurrence presupposes a traumatic involution of a portion of vascular epidermis, capable of regeneration. Thorough excision is the only reliable means of preventing recurrence. Epithelial cyst of the palm. The fibrous capsule of the epithelial cyst is not dense like that of the sebaceous cyst, but usually delicate with few nuclei. It is covered with several layers of more or less cuboid cells with distinct large nuclei, analogous to the outer layers of the epithelium. The central masses of epithelium are transformed into a sebaceous paste containing choles- terin, but never contain hair or other forms of epithelial proliferation. Neuroma; Paraneurotic Fibroma. — Genuine neuroma and "para- neurotic fibroma," classified as neuroma, occurring on the hand and fingers are almost always due to trauma. Foreign bodies (especially pieces of glass) are not infrequently found in them as the immediate cause of the new formation. Multiple Enchondroma. — The metacarpals and phalanges are appar- ently the favorite spots for the development of multiple enchondromata. (Figs. 229 and 230.) Occasionally they grow to an enormous size, to that of a child's head. As long as they consist purely of cartilage they belong to the benign tumors. Their removal is not difficult, but the base of the tumor should be excised carefully, otherwise local recurrence is TUMORS OF THE UASD AND FINGERS. Fig. 229. 371 Multiple enchondromata of the left hand. (v. Bruus.) Fig. 230. X-ray picture of Fig. 229. 372 DISEASES OF THE WRIST AND HAND. possible. Foci of enchondroma embedded in the adjacent medulla may escape detection during the operation, remain latent, and develop secondarily and simulate a recurrence. The growth of an enchondroma usually does not stop with the completion of the general growth. If it undergoes regressive metamorphosis, myxomatous degeneration, or sarcomatous transformation of the interstitial tissue, its very malignant character is soon shown by metastases. Periosteal Osteoma. — Circumscribed periosteal osteoma in the fingers is not a frequent observation in spite of the manifold oppor- tunities for traumatic insults. On account of the hardness of the tumors their proper interpretation is usually easy. The base is broad. They often cause such slight disturbance that their removal will be purely on aesthetic grounds. Chondral osteoma with multiple cartilaginous exostoses is also rare in the fingers; only small osteomata are occasionally found on the carpal bones. The defects accompanying the formation of the exostoses are much more significant for the hand. Exostoses and the production of defects are especially frequent on the ulna and cause a pathological position of abduction of the hand with simultaneous subluxation of the proximal end of the radius. In such cases Bessel-Hagen attempted to correct the position by resecting the lower end of the radius. Sarcoma. — Sarcoma of the skin [sarcoma molluscum], so-called, has no characteristics peculiar to the hand. Important, however, is the often extremely slow growth at the onset and the later rapid development after incomplete operation. Melanotic sarcoma, starting in a nsevus and not infrequently situated by choice in the region of the nail, gives evidence of very pronounced malignancy like all melanotic tumors. Sarcoma originating in the bone is seen on the lower end of the radius or ulna, on the small carpal bones, on the metacarpals or phalanges. It develops pre- ferably from the spongiosa, more rarely from the periosteum, and is more often a soft spindle-cell than round-cell sarcoma. It is almost always soli- tary, attains considerable size, and gradually absorbs the structure of the involved bone so completely that the anatomy of the latter is entirely obliterated. The cartilage usually resists the tumor for a long time, and is sometimes the only evidence of the topography present in the tumor masses. On account of the rich vascularity by which these tumors are distinguished and their great tendency to metastasis they belong among the most malignant tumors known. They occur almost entirely in youth and middle life. Giant-cell sarcoma, in contrast, almost always starts in the periosteum or tendon-sheath. It is more frequent in the long bones. The author has extirpated such in a ten-year-old boy, and repeatedly in middle-aged men from the phalanges, and has demonstrated the anatomical basis and microscopical structure. The prognosis is the same as that of giant-cell sarcoma in general, and is therefore comparatively favorable. Fibrosarcoma may arise in the nerves or tendon-sheaths. The latter origin is more frequent according to the author's microscopical studies than is apparent from the literature. The micro-anatomical details TUMORS OF THE HAM) AM) FINGERS. 373 have been published by Heller. In like manner in a twelve-year-old boy, a man of forty-five, and in a large series of patients ranging in years between these two, the author has been able to obtain unquestion- able microscopical evidence of the genesis in the tendon-sheath. The tendon-sheaths of the ringers are much more frequently affected than those above the wrist, a circumstance which speaks for the influence of trauma. The treatment consists in radical removal. A benign subungual angiosarcoma has been described by Kraske, a small tumor glowing slowly for years in the middle of the nail bed in the form of a bluish spot, producing excruciating pain on pressure; on removing the nail it shows a distinct fibrous capsule and may have produced a shallow depression in the bone. Epithelial Carcinoma. — Epithelial carcinoma occurs almost exclu- sively on the dorsum, and sometimes develops, often under observation of the surgeon, from a formerly benign ulcerating process, a cicatrix, or a wart. Rudolf Volkmann emphasized the malignancy of carcinoma developing from congenital warts in contrast to the benignancy of carcinoma arising from acquired warts. The malignant transformation is shown usually by sudden increase in size, induration of the edges and base of the ulcers, and in warts by beginning spontaneous ulceration, a tendency to bleeding, and often by annoying pruritus. The author has repeatedly been able to follow the process of development in patients who, on account of the distance of their home, consulted him only at rare intervals or through fear of operation kept postponing the proposed operative measures only to have recourse later to the knife. In regard to the frequency of carcinoma in the extremities, according to Rudolf Volkmann and W. Michael, in 105 genuine epithelial carcinomata of the upper extremity, 1)4 were on the back of the hand, 3 in the palm. CHAPTER XXI. OPERATIONS ON THE WRIST AND HAND. GENERAL RULES, LIGATION, PLASTIC OPERATIONS ON THE TENDONS. In the following only the operations will be mentioned which are worthy of consideration on grounds of practical experience. In the last four years the author has had an opportunity to see, treat, and finally to pass judgment on not less than 6000 surgical affections of the hand and wrist. Of these, about 2000 were very complicated injuries, 400 were fractures, 1300 panaritia, 600 severe phlegmon of the hand, 200 frost-bites and burns, 160 tuberculosis, and 200 were tumors. Disregarding the compilation formerly made by Thiersch and Trendelenburg, these figures furnish the basis for the preceding and following observations in regard to the indications and technic of operation. In all operations on the wrist and hand the incision should avoid as much as possible the flexor, namely, the prehensile surface of the hand and fingers; all flaps made to cover in stumps should be taken largely from the flexor surface, and so applied on the dorsum that the line of suture avoids the volar surface. Incisions and sutures should also avoid the end-cushions of the fingers, the incision being made without exception on the side. Strict asepsis is imperative in all procedures on non-infected tissues, as inflammation can leave behind for a long time a sensitiveness during use which is not infrequently taken advantage of by patients who are unwilling or afraid to work. It is advisable to use local anaesthesia as much as possible; for the fingers the Curling-Oberst-Reclus method; about the hand (metacarpus) Schleich's method; about the wrist Oberst's method as improved by Manz, Holscher, and Berndt. The author has already disctissed the limitations of conservative surgery in the treatment of wounds of the fingers and hand; still it should be repeated that although it is an im- portant rule to save as much as possible, it should not be carried to an extreme A faultless covering over the amputated stump is of greatest importance for the future function. Insufficient covering over the stump and thin, sensitive cicatrices adherent to the bone are easily injured and compromise the usefulness and earning-efficiency more than a shorter stump. (See also page 317.) Accordingly in mutilating wounds it is always best to remove sufficient bone to prevent any tension in the sound skin sutured over it. This (374) PLASTIC OPERATIONS ON THE TENDONS. 375 applies also to all wounds of the finger-tips in which the bone is exposed by transverse amputation of the end-portion. It' this end-piece can still be used, one may try to reunite it; if not, the surface of the wound should not be skin-grafted, but rather sufficient hone removed by exarticulation or amputation to obtain a good covering of the soft parts. In order to do justice to the demands of conservative treatment, the author advises the inexperienced to defer the decision as to the removal «>f the finger till the extent of its usefulness is more clearly established. The experienced will usually decide quickly in regard to preserving or amputating. It is impossible to give any generally applicable rule. Every surgeon should always be as conservative as possible in dealing with mutilation of the entire hand, such as is caused by machinery, shot-wounds, etc. "If in this case one should desire to hasten the recovery by removing portions of bone or entire fingers sufficiently to fully cover in the defects and the wounds, an unjustifiable sacrifice would always be made." (Ledderhose.) In describing complicated wounds and their treatment the author has already given space to con- siderations bearing on this subject. Ligation of the Radial Artery. — To ligate the radial artery above the wrist, an incision f to 1{ inches long is sufficient, if made midway between the flexor carpi radialis and the attachment of the supinator longus on the styloid process of the radius; the artery lies beneath the skin and fascia. Ligation of the Ulnar Artery. — This is done with comparative ease to the inner side (ulnar) of the flexor carpi ulnaris, the point of insertion of which (the pisiform bone) is always easily felt; the artery at this point is accompanied by the ulnar nerve and runs over the annular ligament to the palm to form the superficial palmar arch. The vessel is usually accompanied by two veins. Variations in its course are not rare, but cannot be discussed here. In regard to ligation for injuries of the palmar arch, see page 315. For wounds of the nerves the author recommends preferably the " paraneurotic " suture. The indications for operation and the technic of suture of the tendons have already been discussed. Plastic Operations on the Tendons. — The surgeon has to distinguish between division of the tendons and defects of the tendons, and between recent injury and old cases with cicatrization. Recent cases of traumatic division by incised wounds are to be sutured immediately. Recent wounds accompanied by loss of substance will require immediate plastic operation only exceptionally, as in this case the surgeon is usually dealing with extensive injuries the aseptic nature of which must be verified before sacrificing any tendon material for plastic operation, as in the event of infection or necrosis the latter is also sacrificed. There- fore primarily only suture of the tendon or operative abstinence! In old cases with functional loss of the tendon the question is whether there is merely division or defect caused by the injury, or defect follow- ing inflammatory destruction. Cases of the latter kind are almost always hopeless. The usually deep cicatrization with changes in the 376 OPERATIONS ON THE WRIST AND HAND. Fig. 231. adjacent tissues almost exclude any beneficial operation. It will gener- ally depend upon the vocation and desire of the patient as to whether it will not give the best functional result in such cases to remove a part of or the entire finger. In the case of traumatic defect (loss of substance), the extent of the defect and the circumstance as to whether one or more tendons are injured are decisive. Defects up to 4 inches can be over- come by plastic operation. If there are large defects of several tendons, the operative result will leave much to be desired. The most grateful contingent for plastic operations on the tendons of the hand is formed by the cases of diastasis of incised tendons and of paralysis of certain groups of muscles with the func- tion retained in others, such as re- sult from cerebral or spinal infantile paralysis or otherwise uncurable paralysis of the radial, median, or ulnar nerve. For the diastasis following incised wounds there are three possibilities: 1. Plastic flaps. 2. Incomplete su- ture. 3. Tendon-transplantation: (a) by splitting an adjacent tendon and suturing one-half to the distal stump of the divided tendon (in- traparalytic transplantation of iso- functionating tendons) ; (b) by im- planting the distal stump of the severed tendon into an active, ad- jacent tendon (intrafunctional trans- plantation of the paralyzed stump). The methods given under 3 are also suitable for plastic transplantation in paralysis. 1. Plastic Flaps. — The three dia- grams (Fig. 231) explain themselves and do not require further descrip- tion. The author has always been satisfied with the results of method a. author applies the term "incomplete h artificial material is laid between the III Plastic methods of tendon-suture. 2. Incomplete Suture. — The suture " to all methods in whi( Fig. 232. Partial approximation with silk. stumps to produce cicatrization in the defective gap and so restore the function of the tendon (case of Gluck). The simplest method is to connect the stumps with fine silk sutures drawn lightly, not too firmly, AMPUTATION AND EXABTICULATION. ;;77 together. (Fig. I':!-'. In the figure only two sutures arc shown, although it is advisable to use more. This method presupposes thai the cicatrized and adherent stumps are first loosened. The result of the method is uncertain. ;!. Tendon-transplantation. (Fig. i'-'!.').) I to. 233. Tendon-transplantation: a, intfaparalytic transplantation of a split portion of an isofunctionating tendon; b, intrafunctional implantation of the paralytic stump. AMPUTATION AND EXARTICULATION. Ever since anaesthesia, artificial anaemia, and asepsis have been added to surgical technics amputation and exarticulation have become such simple surgical measures that each problem is easily accessible to the knife if the anatomy is considered. The author therefore omits many details which form a part of the operative course on the cadaver and confines himself to describing the principle methods of incision. Exarticulation of the Hand. — Amputation of the hand at the wrist- joint is only admissible when no portion of the hand can be saved for a stump. The formation of the flap is important; the covering is best taken from the volar or radial side (thenar flap of Dubreuil). Steps in the operation: forcible flexion of the hand; curved dorsal skin-flap convex downward, beginning \ inch below the styloid process of the ulna and ending % inch below the styloid process of the radius; division of the extensors and the lateral and dorsal ligaments; disarticulation of the carpus; transverse division of the flexor tendons; formation of a full volar flap to be sutured on the dorsum ; ligation of the ulnar and radial artery and occasionally of a terminal branch of the interosseus; high division of the median, ulnar, and radial nerves. The flap may be taken from the radial side, including the muscles of the thumb with advantage, because by this means any cicatrization over the most prom- inent part of the stump, namely, the styloid process of the radius, is avoided; or a circular incision may be made beginning 1 to 1 \ inches below the styloid process. Amputation of the Metacarpus Excluding the Thumb. — This ampu- tation is required especially for extensive mutilation, gunshot-wounds, etc. One should consider well beforehand how much can be saved of 378 OPERATIONS ON THE WRIST AND HAND. the metacarpals in order to preserve the prehensile power as much as possible. The aim is: the greatest possible preservation of the meta- carpals, formation of a good flap from the palm; if this is not possible, from the dorsum or adjacent remnants of skin. Steps in the operation: dissection upward of a semicircular volar flap close to the metacarpals to the point of amputation of the bones; transverse incision of the skin on the dorsum \ inch below the level of the stumps, removal of the bones with a tendon saw after dividing the interossei; ligation of the five digital arteries; high division of the nerves; suture. Amputation of a Single Metacarpal. — Amputation of the thumb is best performed (Walther, French method) by forcibly abducting the thumb and earning the knife through the middle of the interdigital fold close to the first metacarpal and then upward, the joint between the first metacarpal and trapezius being opened correspondingly from the ulnar side; the ligaments are divided about the base of the metacarpal, the knife carried to the radial side, and the division continued downward with the formation of a large flap. The metacarpal is also easily disarticulated through an oval (racket) incision, the point being proximal, the base distal. Kocher recommends that all the muscles of the thumb should be preserved intact and the metacarpus disarticulated through a dorsal incision running along the ulnar side of the first metacarpal and ending as an oval incision at the level of the first phalanx. For exarticulation or amputation of the third or fourth metacarpal one uses a volar and dorsal longitudinal incision continued laterally below to meet at the sides at the level of the interdigital folds. The latter are then incised and the parts dissected close to the bone to the point of amputation or to the joint; the adjacent metacarpals are retracted laterallv, the bone divided with a pointed saw or disarticulated at the joint; ligation; careful suture, especially in the palm. To avoid cicatrices in the palm, the metacarpal may be removed through a dorsal longitudinal incision ending as an oval incision at the level of the first phalanx (racket incision). Amputation of the Fingers at the Metacarpophalangeal Joint. — For the thumb and index finger this is best performed by making an external lateral flap; for the fifth finger by an internal lateral flap; the third and fourth by an oval incision with the point on the dorsum. The line of the joint is easily felt on the dorsum by moderately flexing the finger, and can be seen by pulling on the finger. In making the oval incision the finger is hyperextended. In suturing, in order to obtain a movable covering over the head of the metacarpals, the lateral and volar incisions should not be made too high. Slight excess of skin does not impair the later usefulness of the hand. In disarticulating the finger the two digital arteries are to be ligated, and the adjacent nerves freed and cut off at a higher level. In amputating the middle and ring fingers, if it is possible, particularly if the wound is aseptic, the author always removes the head of the metacarpal so as to be able to approximate the heads of the adjacent metacarpals and RESECTION OF THE WRIST-JOINT. 379 insure the best possible closure of the hand. For this purpose the incision is made a little higher on the dorsum, , to 1 inch above the joint. The finger is disarticulated, the head of the metacarpal freed to above its neck, and sawed off with a pointed saw or removed with the sharp Liston bone-shears. Exarticulation of the Middle and End- phalanges.- -The continua- tion of the interphalangeal fold between the first and middle phalanges marks the point on the dorsum for the incision to open the joint. The fold between the second and third phalanges is not an accurate guide, so that it is better to make the incision according to the old rule \ inch below the most prominent point of the joint, the latter being flexed forcibly. This opens the joint and gives sufficient material for the flap. The lateral ligaments are then divided; a full volar flap is then made which should include the insertion of the tendon of the flexor profundus and all the soft parts. Amputation of the Phalanges. — Large dorsal and volar flaps are formed by a circular incision from which two lateral incisions run upward; the ends of the tendons should be sutured together over the stump, in deciding between amputation and exarticulation it should be remem- bered that even small stumps of the middle or end-phalanges are useful, whereas short stumps of the first phalanx are in the way, so that in the latter case Adelmann's operation as described is preferable. In septic affections exarticulation is always preferable to amputation. RESECTION OF THE WRIST-JOINT. Resection at the wrist-joint or of the entire wrist-joint is indicated for wounds, especially gunshot-wounds, septic infection, and tuber- culosis. The available statistics of gunshot-wounds are chiefly from the preantiseptic period. Present knowledge of the action of modern firearms would seem to indicate that the treatment of the greater number of gunshot-wounds should be conservative. In wounds from heavy ordnance, as in the case of numerous machinery injuries, the damage to the wrist constitutes only a part of the mutilations involving the hand or forearm, but in this case typical primary resection does not come in question. In regard to the indication for surgical interference in septic processes the author has already spoken in describing the latter. The mode, of procedure will depend upon the site of the infection or lie determined by the same general technical considerations applying to tuberculosis of the wrist. For this reason the author desires to discuss the latter more in detail. The prognosis in general of resection of the wrist should be mentioned briefly. Its relatively unfavorable functional results have been reported from all sides, and have caused many surgeons to hesitate to perform resection. In all cases in which the author was compelled to do primary partial resection for complicated injuries, partial mangling of the carpal bones, or compound dislocations, he has obtained either partial or 380 OPERATIONS ON THE WRIST AND HAND. complete ankylosis at the wrist. The result is usually due to the severity of the injury. On the other hand, in almost all these cases in which all useless portions of bone were removed recovery was rapid and uninterrupted. The results of resection for sepsis were about the same. The author has never had to amputate secondarily, but never- theless almost always obtained ankylosed joints. The treatment here is concerned chiefly in checking the infection with all the means of drainage and packing. The functional results in tuberculosis are somewhat different, espe- cially if the end of the radius and ulna, and if possible also part of the distal carpal bones, can be preserved, in which case the subsequent usefulness of the hand may be very satisfactory. In most of the cases the author begins the treatment by injecting iodoform. The action of the latter in patients up to the fortieth year is often surprisingly beneficial. Even in the cases in which the tuberculous process appears to be worse after the first injection persistence in its use is often rewarded by excellent results. If the examination, however, especially with the .r-ray, leaves no doubt as to the involvement of the larger part of the carpal bones, and if the age and general condition of the patient do not demand amputation, careful total resection of the wrist may be well fitted to restore fairly good use of the hand. The creation of useful methods of operation is closely connected with the names Lister, v. Langenbeck, Oilier, Konig, and Kocher. Resection of the wrist is not a simple operation under any conditions' all arteries, nerves, tendons, and, if possible, tendon-sheaths should be avoided, and as much of the periosteum preserved as possible. The ligaments are in part very firm; the anatomy is obliterated by the inflammatory processes. On the other hand, softening or partial destruction of the bones often make the operation easier than expected. All resections should be done under application of the Esmarch. Total Resection of the Carpus with Lister's Bilateral Longitudinal Incision. — Based upon the experience that the infectious process often advances along the complicated communications of the joints, Lister advocated total resection. His method is as follows: A longitudinal incision 1 inch long is made upward from the styloid process of the radius and down to the bone; from the same point on the process a skin-incision is carried 1 inch downward to the inner side of the first metacarpophalangeal joint, to avoid the tendons of the abductor pollicis longus, extensor pollicis longus and brevis; from this point it is con- tinued on the dorsum to the middle of the radial border of the second metacarpal. The insertions of the extensor carpi radialis longus and brevis are then freed and the periosteum lifted off in both these incisions. A second incision 1 inch long is then made from the styloid process of the ulna upward down to the bone and 1 inch downward to the base of the fifth metacarpal. The insertion of the extensor carpi ulnaris is divided, the tendon being lifted off with the skin. The extensor tendons lying between the two incisions, radial and ulnar, are then lifted off carefully and the dorsal and inner lateral ligament divided. RESECTION OF THE WRIST- JOINT. 33 \ The flexor tendons are lifted oil' in the same way; the unciform process of the unciform is cut with bone-shears, the carpal hones extracted through the ulnar incision with bullet-forceps, the hones of the forearm protruded through the ulnar incision and sawed off, leaving the styloid process of the ulna. Lister finally added resection of the base of the metacarpals and the trapezium. The pisiform and unciform are left, the radial incision closed, the ulnar incision left open in the middle. The radial artery should he avoided in removing the trapezium. The latter can often be preserved because it is rarely diseased. Huter saves the articular ends of the radius and ulna if possible (on account of pro- nation and supination); also the base of the metacarpals. The objection made to Lister's method, that the ulnar artery is injured by the ulnar incision, is overcome if the proximal incision is shortened. v. Langenbeck's Dorsoradial Incision.— This incision is much sim- pler, and is in general use at the present time. Beginning at the middle of the second metacarpal close to its ulnar border, an incision is made about 3-V inches upward over the epiphysis of the radius. The common tendon-sheath of the extensors, including that of the index ringer, is to be avoided and retracted toward the ulna. Between it and the sheath of the extensor pollicis longus the annular ligament is incised down to the radius. The edges of the wound are retracted, the capsule of the radiocarpal joint divided longitudinally and peeled off with the ligaments and periosteum. The elevator is then pushed beneath the tendons in the grooves on the back of the radius and the tendons, sheaths, and ligaments carefully lifted off together and drawn toward the ulna. The hand is then flexed, the proximal row of carpal bones removed, beginning with the scaphoid and the trapezium included if necessary. The intercarpal ligaments should always be cut clean through. The distal row are easily approached from between the trapezium and trapezoid. The thumb is abducted, the dorsal ligaments of the carpometacarpal joint divided, and finally, if indicated, the hand is adducted, the articular ends of the radius and ulna protruded and sawed off. Previous to this the lateral ligaments are freed sub- periosteally. The posterior carpal branch of the radial is to be avoided. If the base of the metacarpus is to be removed, the incision is prolonged somewhat over the back of the hand. Occasionally Hitter's proposed drainage by counteropening at the ulnar side may be used. Oilier, who prefers partial resection or excochleation in young subjects according to the extent of the disease, has obtained brilliant results with total resection in adults. He uses v. Langenbeck's incision and adds an ulnar incision similar to Lister's. Treves has expressed himself as an advocate of Oilier 's method. Guided by the experience that the radius and ulna are usually uninvolved, Konig uses v. Langenbeck's incision, but separates the tendon-sheaths only slightly from the dorsum of the radius, saves the articular cartilage of the radius as far as possible, and merely removes the synovialis radically with a strong sharp double- spoon; he pries out the proximal row of soft carpal bones, then the distal row, leaving the pisiform and trapezium. All synovial remnants 382 OPERATIONS ON THE WRIST AND HAND. are then carefully removed. If it is accessary exceptionally to excise the radio-ulnar or metacarpal articular surfaces, Konig uses the chisel, a pointed saw, or a heavy knife. Kocher's Dorso-ulnar Incision. — The occasional volar subluxation of the hand and great impairment of extension following v. Langenbeck's operation are ascribed by Kocher to the expected functional loss of the radial extensors, which are separated from their insertions on the second and third metacarpals. He therefore uses a simple dorso-ulnar Fig. 234. Incision for resecting the wrist: I.isfer; v. Ltingenbeck; v. Kocher. incision about 3 inches long, similar to the earlier method of Chassaignac. (See Fig. 234, broken line.) The hand is slightly abducted and the skin incision carried from the middle of the fifth metacarpal to the middle of the wrist, and thence upward in the middle of the dorsal surface of the forearm. At the lower end the basilic vein and the dorsal cutaneous branch of the ulnar nerve are to be avoided. After dividing the fascia and the annular ligament the tendon-sheaths of the extensor digiti minimi proprius and RESECTION OF THE WRIST JOINT. extensor communis are opened at the metacarpophalangeal joint, the ten- dons drawn to the radial side, and beneath the tendons the capsule incised at the base of the fifth metacarpal, at the unciform, the cuneiform, and ulna. The capsule is then separated « » t V toward the ulna and with it the attachment of the tendon of the extensor carpi ulnaris at the base of the fifth metacarpal. Above, the tendon is drawn out of the groove on the ulna and the capsule pried off about the ulna. If the radio-ulnar joint is involved, the disk should be removed. The pisiform is left with the tendon of the flexor carpi ulnaris attached. r \ 'he capsule is freed from the fifth, fourth, and third metacarpals on the flexor side and on the anterior surface of the radius, the attachment of the tendon of the flexor carpi radialis to the second metacarpal being left intact. The capsule on the dorsal surface of the lower end of the radius is then divided as far as the extensors of the thumb and the tendons lifted out of their grooves. The tendons of the extensors are left intact upon the dorsal surface of the third and fifth metacarpals. The hand is dislocated forcibly by abducting and flexing, so that the thumb touches the radial side of the forearm and the extensor tendons lie upon the outer side of the radius. The capsule on the outer border of the radius can now be divided and the attachment of the supinator longus lifted off. Kocher claims as the advantage of this method that the division of the extensor carpi ulnaris does not impair extension as much as the division of the two radial extensors; further, the extensor tendons are not so liable to be exposed by the dorso-ulnar incision as by the radial incision. The significance of damage to the extensor tendon of the little finger is naturally less than in the case of the index finger. Further, the unciform process of the unciform is more easily exposed and divided. On the other hand, Kocher admits that the trapezium and trapezoid are less accessible, and recognizes the advantage of the dorsoradial incision in the cases in which the disease lies chiefly at the radial side of the wrist. A plan of operation accurately mapped out with reference to the anatomy aids the subsequent functional result of resection of the wrist-joint. After packing or draining the cavity and applying sufficient absorbent dressing it is important to immobilize the hand in extension upon a splint. Lister's splint fulfils this requirement. The extension or hyper- extension position is preferable because it usually gives a much better functional result. The circular plaster splint with a fenestrum is much used. The author employs an anterior moulded plaster-strip splint. The fingers should always be left free, and should be exercised in a few days. The extension position may be maintained with advantage in a splint for some time after complete recovery ffour to six week> or longer (three to six months) because in a number of cases the proper position can only be secured in this way. The aesthetic and functional results are not infrequently surprisingly favorable. 384 OPERATIONS ON THE WRIST AND HAND. RESECTION AND SEQUESTROTOMY OF THE METACARPALS AND PHALANGES AND THEIR JOINTS. The indication for resection is given almost exclusively by tuberculous myelitis (or periostitis), whereas septic processes may call for seques- trotomv. Conservative treatment is indicated in the case of wounds. If the surgeon is dealing with inflammatory destruction of a meta- carpal involving the head, the incision is made directly over the meta- carpophalangeal joint and to the ulnar side of the extensor tendons. The soft parts, including the tendons, are pushed aside with the elevator and blunt retractors and the joint incised. The head and then the entire metacarpal is freed from its connections. If the base can be saved, it is of advantage for the protection of the carpometacarpal joint. In like manner the base of the corresponding first phalanx is saved if possible. The finger recedes upward in the row of fingers toward the carpus, but may retain its full power. The preservation of the head of the metacarpus is naturally a further advantage. The after-treatment is on general principles. To excise a phalanx, the incision is made to the side of the extensor tendons, but should avoid the vessels and nerves. To prevent secondary lateral (ulnar or radial) deviation, it is of advantage to make a bilateral incision. Excision with knife and elevator and the after-treatment are simple. A splint should be worn for some time to prevent lateral deformity. Sequestrotomy of a metacarpal usually requires a similar procedure, chiselling off of the dorsal covering and widening of the bone cavity as in every other sequestrotomy. In the phalanx, as the process is usually recent and the new formation of bone soft, a single longitudinal incision is usually sufficient to expose the sequestrum. Sequestra occur chiefly in the end-phalanges, and their extraction here is one of the simplest surgical operations. Resection of the metacarpophalangeal and interphalangeal joints may be required to check a septic or tuberculous process and to restore the best possible function; this latter aim is not usually attained if one of the adjacent bones is involved to any extent. If possible, one of the joint-surfaces should be saved. Even if both are sacrificed, however, a certain amount of mobility may be preserved. Resection of the metacarpal-head for irreducible dislocation of the thumb, an operation rarely required, was performed by the author in one instance with a very satisfactory result. The incision to resect the joint should not be too small to allow full inspection and thorough technic: for an adult metacarpophalangeal joint not less than \\ inches, for an interphalangeal joint not under 1 inch. The tendons, nerves, and vessels are to be avoided the same as in resection of the bone, namely, by an incision at the side of the extensor tendons. The joint is then opened, all diseased tissue removed, and the wound packed and partly closed. A smaller or larger section of the adjacent bone may be removed through the same incision, if desirable, by means of Liston's cutting bone-forceps or Luer's rongeur- forceps. In a large number of cases the final result is good. MALFORMATIONS, INJURIES, AND DISEASES OE THE HIE AND THIGH. l'.v Prop. Dr. A. HOFI A. MALFORMATIONS, INJURIES, AND DISEASES OF THE HIP. Anatomy and Physiology. — The hip corresponds to the articulation of the pelvis with the lower extremity. The hip-joint is composed of the acetabulum of the os innominatum and the head of the femur. The acetabulum, formed by the ilium, ischium, and os pubis, is a hemispherical cavity adapted to receive the head of the femur by the deposit of a thick, sharp-edged, fibrocartilaginous ring upon its free border (the cotyloid cartilage). At the anterior lower margin there is a bridged gap, the cotyloid notch. The cavity is covered with cartilage only where the cotyloid ligament is attached, the floor being covered merely with synovial membrane and containing a certain amount of loose adipose tissue. The articular head of the femur is nearly hemispherical, being slightly flattened. The cavity and head therefore do not fit exactly, so that the surfaces are not in contact throughout in all positions of the extremity. Slightlv below the summit of the head the ligamentum teres is attached O t c in a slight depression, its fibres merging in part immediately into the hyaline, cartilaginous covering of the articular surface. The head is connected by its neck to the shaft of the femur, the junction being indicated by the intertrochanteric line between the greater and lesser trochanters. In the newborn the upper end of the femur is like that of the humerus, the articular cartilage resting like a cap upon the shaft of the bone. The first primary centre forms in the head at the end of the first year. The trochanter major forms in the second year. In the fourth year begin the ossification of the greater trochanter and its demarcation from the cartilage of the head. The demarcation is complete at the sixth year. (Konig.) The capsule of the joint with reference to its breadth is the reverse of that of the shoulder-joint, the latter being narrower at its insertion on the scapula than at its attachment on the humerus, whereas the former is narrower at the femur than at the acetabular margin, and Vol. III.— 25 (385) 386 MALFORMATIONS, INJURIES AXD DISEASES OF THE HIP. so represents a cone the point of which is directed downward, the base upward. It arises from the entire circumference of the cavity, but is not attached all around the neck of the femur, but only on the front and sides, especially on the intertrochanteric line. Its posterior wall is not immediately connected with the hone, but ends in a sharply defined, free border from which the synovial membrane is continued on over the neck of the femur. (Fig. 235.) The wall of the capsule varies in thickness and firmness, the weakest parts being behind at the lower border where the synovial membrane passes over on to the Fig. 235. Fmntal section through the hip-joint of an eieht-year-old hoy. U, cross-section of the ilium; c, cartilaginous disk between the pubis and ischium; pu, cross-section of the descending ramus of the pubis, attached to the above cartilage by the upper margin of the obturator membrane; tg, cotyloid cartilage; ta, tran.-ver>e ligament of acetabulum; '/■•>. zona orbicularis of the joint capsule; ctmj, epiphysis of the great trochanter; If. ligamentum teres femoris. (v. Bruns.) neck of the femur. In front there are reinforcing bands, the most im- portant of which is the iliofemoral ligament, or ligament of Bertini (Fig. 235), arising \ inch in width from the anterior inferior spine of the ilium and attaining a width of 3 inches as it diverges into two arms to be attached to the intertrochanteric line. It was, therefore, called the Y-ligament by Bigelow, who recognized its important influence upon the form and reduction of dislocations of the hip-joint. The trunk of the Y is often very short if the division of the inner and outer arms MALFORMATIONS, INJURIES AND DISEASES OF THE HIP. ;;,s7 Fig 236. begins a short distance from its origin. These arms merge into the rest of the capsule without any sharp demarcation, but not with all their fibres, as lateral bundles run around both sides of the neck to unite behind and form a girdle, the zona orbicularis, encircling the neek somewhat as the annular ligament surrounds the head of the radius. Tin- Y-ligament is extremely strong and resistant. In thickness it exceeds the patellar ligament and the tendo Aehillis. In a well-developed man 1 1(H) pounds are required to tear it. The two other reinforcing bands of the capsule, the pubofemoral and ischiocapsular ligaments, are less firm, the former running from the pubic spine to the lesser trochanter, the latter from the tuber ischii to the posterior wall of the capsule. The ligamentum teres, running from the cotyloid notch to the head of the femur conveys the nutrient vessels to the latter. That the contact be- tween head and cavity is not over- come by the weight of the limb is clue to external air pressure, as demonstrated by the experiments of the Weber brothers. In the living subject there are in addition the valve action of the cotyloid cartilage, the cohesion of the synovialis, and the influence of the muscles covering the hip-joint. Of the latter, the adductors, the pectineus, and the gracilis lie to the inner side of the joint; the iliopsoas, sartorius, rectus femoris, and tensor fasciae lata? in front; the glutei, pyriformis, obtur- ator interims, with the gemelli, quadratus femoris, and obturator extemus, to the outer side; and behind, the biceps, semitendinosus, and semimembranosus. These strong, reinforcing soft parts together form a wall which make the joint extremely inaccessible to palpation, especially if covered in addition with a well-developed cushion of fat. Nevertheless the position of the hip-joint can be determined from without with approximate accuracy. In children a plane passing horizontally through the tip of the great trochanter about touches the highest point on the head of the femur. In adults the trochanter lies somewhat lower, so that the same plane passes through the middle of the head. If the femur is slightly flexed, the tip of the great trochanter lies in a line drawn from the anterior superior spine to the tuber ischii ( Roser-Xclaton's line, Fig. 237). If the trochanter cannot be felt on account of swelling, the position of the joint can be determined accurately by erecting a perpendicular at Iliofemoral ligament; Y-ligament of Bigelow. 388 MALFORMATIONS, INJURIES AND DISEASES OF THE HIP. the middle of a line drawn between the anterior superior spine and the symphysis; tins line divides the joint approximately into two equal parts. (Konig. The hip-joint, like the shoulder-joint, is a free arthrodia. Its move- ments are possible in all conceivable directions in any axis passing through the middle of the head. The movements are divisible into those about three principal axes from which all the others can be combined: 1. Those about a frontal axis drawn transversely through both heads of the femurs, flexion and extension. 2. Those about a sagittal axis drawn perpendicular to the former, abduction and adduction. 3. Those about a vertical axis coincident with that of the femur, inward and outward rotation. Under normal conditions abduction and adduction are widest, flexion and extension less so, rotation least ample. Fig. 237. The Roser-X^ls Each of these movements has its physiological limitation. Flexion is usually limited by the contact of the soft parts of the thigh with those of the abdomen. In very thin individuals with marked kyphosis the neck of the femur may strike against the upper rim of the acetabulum. Extension is limited by the iliofemoral ligament; the latter also checks save movements about both other axes, the outer arm limiting adduction and outward rotation, the inner arm and the pubofemoral ligament limiting abduction and inward rotation, the action of both arms of the ligament being increased by extension. Abduction, adduc- tion, and rotation are therefore greater if the thigh is flexed. The mobility of the thigh depends further upon the suppleness and reciprocal relation of the muscles, as demonstrated by the litheness of contortionist-. CHAPTER XXII. MALFORMATIONS OF THE HIP-JOINT. CONGENITAL DISLOCATION OF THE HIP-JOINT. Congenital dislocation of the hip-joint is the most frequent of all inherited dislocations. According to Kronlein, in addition to the 90 cases of hip dislocations seen in the Berlin surgical polyclinic there were only 5 of the humerus, 2 of the head of the radius, and 1 of the knee-joint. The author's statistics of the frequency of congenital dislocation of the hip compared to other surgical diseases give the following: in 10,000 surgical patients there were 7 of these cases (0.07 per cent); in 1444 cases of deformity there were 7 congenital hip dislocations (0.49 per cent.). The affection appears to vary in different geographical areas, being quite frequent in some countries, rare in others. Of 898 cases observed by various authors, 105 were in males (12 per cent.) and 793 in females (88 per cent.). The deformity is therefore seven times more frequent in females than in males. It is more often unilateral than bilateral: 576 unilateral to 322 bilateral. In the unilateral form the left side is involved somewhat more frequently than the right. There does not seem to be any sexual predisposition to this or that form of dislocation, as emphasized by Kronlein against the poorly founded assertion of Gueniot. Etiology. — Numerous theories are advanced in regard to the causation of congenital dislocation of the hip: 1. The so-called congenital dislocation is of a traumatic nature, and is due to external violence affecting the uterus during pregnancy (Hippoc- rates, A. Pare, Cruveilhier) or to forcible traction upon the foot during delivery (Capuron, Chelius, d'Outrepont, J. L. Petit, Phelps, Brod- hurst). Disregarding the fact that in the author's experience fracture is more liable to be produced than dislocation by such an injury, this theory is untenable because in the large majority of cases there is no history of such trauma. 2. The dislocation is pathological, and is due either to weakening and relaxation of the ligaments of the joint (Sedillot, Stromeyer), to an intra- uterine inflammation of the joint, hydrops of the joint (Parise), fungous synovitis with effusion (Verneuil, Broca, Pfender), or caries of the joint and destruction of the capsule (Morel-Lavallee, Albers, v. Ammon). Although intrauterine inflammation of the joint certainly occurs, it is not responsible for the dislocation, as there is usually an absence of any sign of previous inflammation in congenital dislocation. ( 389 ) 390 MALFORMATIONS OF THE HIP-JOINT. 3. The dislocation is due to the peculiar position of the lower extrem- ities in utero: (a) Dupuytren thinks it is possible that if the tissues are abnormally yielding, the pressure of the head against the posterior inferior part of the capsule, as induced by a strongly flexed position of the thigh, may occasionally cause the dislocation. (6) Roser ascribes the dislocation to abnormal adduction of the thigh resulting from the pressure due to insufficient amniotic fluid, (c) Lorenz believes that a gradual stretching of the capsule takes place with simultaneous prying out of the head from the cavity under the influence of constant, excessive flexion and adduction of the thigh. The departure of the head causes atrophy of the cavity, although the head still lies opposite the cavity and is merely lifted away from it. The displacement of the head upward results secondarily after birth from the traction of the muscles and the body-weight, (d) Schanz conceives that with insufficient amniotic fluid the continuous elastic pressure of the wall of the uterus forces the flexed and adducted head out of the cavity. The same pressure is supposed to produce the typical deformity of the femur, (e) Hirsch believes that in addition to the pressure due to insufficient amniotic fluid there is a further dislocating force, namely, the power of growth of the foetal femur. By this inherent physiological power the femur is supposed to grow beyond the cavity. 4. The dislocation is due to muscular retraction, which in turn is due to a change in the central nervous system. (Guerin.) Guerin is right about the muscular retraction, but advanced this theory for the sake of his tenotomy. The retraction does take place, but is not the cause but rather the result of the deformity, as will be discussed fully under the pathological anatomy. 5. The dislocation is due to intrauterine paralysis of the muscles running from the pelvis to the great trochanter. The paralysis is gradually followed by relaxation of the ligaments, and this in turn by the dislocation, especially later when the child begins to walk and support the body-weight. (Verneuil.) It is true that such muscular paralyses result from spinal disease in infancy, but the resulting dislo- cation is not to be designated as congenital but as paralytic ; it will be described in a separate section. 6. The dislocation is referable to maldevelopment preventing the formation of the normal articular surfaces, v. Amnion states that it is due to arrestment at an early period of foetal life. v. Ammon's theory was later substantiated and strengthened by a series of studies under- taken to learn more of the nature of the inhibition. (Dollinger, Grawitz, Holzmann, Lannelongue.) According to Dollinger, the arrestment is due to an early ossification of the Y-shaped cartilage of the cavity or to an insufficient production of bone from this cartilage. Grawitz recog- nizes only the latter cause. Holzmann regards a primary arrestment in the development of the cavity as the cause. Lannelongue recently ad- vanced the theory that the malformation of the cavity is of central origin. A chain of evidence is produced in support of the theory of malforma- tion, namely, that the dislocation is frequently accompanied by other CONGENITAL DISLOCATION OF THE HIP-JOINT. 3 to 1 inch higher for some time on the other foot. In bilateral dislocation Lorenz advises to reduce one joint and then the other after the first lias become stable, cither by the bloodless method or by open operation. The author has found that one can do both sides very well at one sitting. The splint must then be applied with both thighs abducted to a right angle and hyperextended. ( Fig. 251.) This first splint is changed after the second or third week and the thighs adducted so that the patients can go about to sonic extent at least unaided. Fig. 251. \ pj*r rr p*^ ^£ "i-^K*" 91 f X The bandage applied after the reduction of bilateral dislocation, showing a favorite method of progression on a chair. (Whitman.) Recently Lorenz' method has been modified by Kiimmell, who usually omits the preliminary extension and begins by abducting the thigh. A further modification which the author would like to recommend is that the thigh, after being abducted to a right angle and rotated outward forcibly, should be carried back and forward toward the body from the horizontal like a pump-handle with gradually increasing hyperextension. The cavity is thus widened very satisfactorily and the tense anterior wall of the capsule stretched thoroughly. For example, the author was able to reduce a dislocation in an older child in whom Lorenz had 410 MALFORMATIONS OF THE HIP-JOINT. attempted reduction unsuccessfully. Further, the author does not immobilize the limbs in strong abduction and outward rotation, but in slight abduction and inward rotation. Much time is thus saved and the results arc better with reference to permanent reduction. Lorenz' method was the first to make bloodless reduction popular, and the question is now as to its final results. The experience gained from many hundreds of cases has shown that in the great majority of them reduction takes place with a jerk that can be heard or felt. There are a few cases — Lorenz and the author have reported such — in which reduction was impossible, even in very young children. The retention of the head in its cavity is a different matter. Here most of the cases are in the minority in which the head actually remained per- manently in the cavity, and which were verified by the a*-ray and the anatomical specimen. In the great majority of instances the head slips out forward and upward over the cavity in time and forms for itself a stable secondary position beneath and close to the anterior inferior spine. The neck of the femur then usually lies entirely in the sagittal plane and can be felt throughout its full extent. The thigh often assumes a position of pronounced outward rotation and abduction. Usually the head is freely movable; the cases in which reduction actually persists are characterized by stiffness in the joint lasting for some time. The marked abduction does not require any special treatment. It usually disappears finally. Even the annoying outward rotation of the thigh at the outset lessens with time, so that secondary operation to improve the position of the thigh is rare. The result of the Lorenz bloodless method is therefore an actual reduction in rare cases, a transposition of the head in the majority of the cases, so that the head retains the same position permanently as obtained by the methods of Paci and Schede. This result cannot cause surprise. Evervone who knows the pathological anatomy of hip dislo- cation must admit from the first that the head cannot secure any firm hold in the cavity, even if brought against it. The deformed head cannot fit into the triangular cavity, and as the latter represents an inclined plane the head has to slide upward over it even if both bones are in accurate apposition. Frequently this is not the case, however, especially if the ligamentum teres is present, for the ligament then necessarily becomes interposed between the head and the cavity and prevents permanent contact of the two bones. The author therefore believes that the method recently proposed by Witzel to prevent the ascent of the head by driving in nails above it will not meet with very much success. Lorenz' method is a great advance, however, for the functional results are generally very satisfactory. Children with unilateral dislocation often walk so well that the previous deformity is hardly noticeable, and those with bilateral dislocation lose the lordosis and walk with only slight swaying of the body. The method is limited, however, by the age of the patient. Beyond the sixth year it is very seldom successful, and Lorenz does not advise its use after the tenth year. The dangers CONGENITAL DISLOCATION OF THE HIP-JOINT. Ill of bloodless reduction in younger children, according to Lorenz, are slight. In older patients they consist in laceration <>f the soft parts, suppuration of the 1 >l< »< >< ! extravasate, suppuration of the hip-joint, paralysis of the sciatic, fracture of the femur in fact, the author has had a case with convulsions, symptoms similar to shock, and death. These drawbacks warn the surgeon not to force the reduction or to attempt it in children too old. Mikulicz' Method. As the last of the bloodless methods, but by no means the worst, should be mentioned that of Mikulicz for very young children. Mikulicz has contrived a very ingenious apparatus in which he places the child for several hours daily with the limbs extended, abducted, and rotated outward, thus bringing the head gradually down opposite the acetabulum. I )uring the rest of the day the child is allowed to go about. Great stress is also laid upon the strengthening of the Fro. 252. The Mikulicz-Hoffa type of apparatus for 1 lie reduction of congenital dislocation of the hip in young children muscles. The author has used Mikulicz' apparatus many times and found it very practical. The only disadvantage is the length of time required; the author has never obtained a positive result before one to one and a half years. This disadvantage can he overcome by combining the method with that of Lorenz. For children up to two years the author first uses the Lorenz method under ana\sth( sia, and so brings the head and cavity into contact at once. After two or three weeks the plaster splint is removed and the child laid in Mikulicz' apparatus. As the head is now opposite the cavity it is better not to rotate the limb outward in the apparatus, but inward on account of the usual anteversion of the head. The author has therefore modified the Mikulicz apparatus SO that the limb can be rotated inward or outward in it. Fig. 252 shows the modified apparatus, in which the children lie several hours during the day, or even at night, with the limbs extended, 412 MALFORMATIONS OF THE HIP- JOINT. abducted, and rotated inward. They become accustomed to it so rapidly that they sleep the entire night in it. Every day the thigh mus- cles, especially the hip muscles, are massaged and strengthened by exer- cises. When moving about the children wear the jacket shown in Fig. 248. By this method the author has obtained excellent results and in a few cases absolute recovery, as shown by the local condition, the gait, and the a;-ray. In other instances reduction was not complete, but merely a transposition of the head, as obtained by the methods of Paci, Lorenz, and Schede, yet with a very good functional result. So at the present time, in the bloodless methods of Paci, Schede, Lorenz, and Mikulicz, we have the possibility of reducing con- genital dislocation of the hip in a manner formerly regarded as impos- sible. Naturally, in view of the existing defects of the bones, the children cannot be made absolutely normal, but satisfactory functional results can be obtained. Which method to apply in the individual case will be determined by the individuality of the operator and the patient. Generally the author uses Mikulicz' method for children up to the second year, as it is the most comfortable and most rapid. For older children he uses either the method of Schede or Lorenz, according to the case, and follows out the after-treatment as given by these authors. There are therefore many roads to success as far as allowed by the anatomical peculiarity of the joint affected. If the difficulties, however, are insurmountable, and reduction is impossible or followed by reluxa- tion, the open operation is still useful and often produces an almost ideal result in these severe cases. Guerin was the first to describe the open operation. He proceeded on the theory of primary muscular retraction, and accordingly did a tenotomy of all muscles about the great trochanter. At the same time he turned his attention to the maldevelopment of the cavity and scarified the head subcutaneously in order to make it adhere to the ilium. The results, however, were not permanent. His tenotomy was repeated by Bouvier, the younger Pravaz, Corridge, and especially by Brodhurst, who is supposed to have been successful with this operation. As a curiosity should be mentioned the operation of the celebrated osteotomist Mayer, of Wiirzburg, namely, osteotomy of the other femur to make it the same length as the affected limb. Hitter constructed a rational plan of operation: After exposing and removing the atrophic head he intended to unite periosteal flaps freed from the femur and ilium, but did not ever perform it. De Paoli and Israel nailed and sutured the head of the femur to the ilium without success. Konig, utilizing the knowledge acquired in transplantation of bone-periosteal flaps in plastic operations on the nose, conceived of forming a new cavity or a bony barrier to prevent the outward displace- ment of the head by chiselling off a flap from the ilium, turning it down and suturing it to the capsule, at the same time making traction on the limb to draw down the head of the femur as far as possible, and, further, to hold it there after the operation. The operation was performed by Konig, Gussenbauer, and Schonborn, and produced some improvement, CONGENITAL DISLOCATION OF THE HIP-JOINT. 413 but was later abandoned by Konig after he had convinced himself that the author's operation gave better results. Resection of the head of the femur, first employed by Hose and Rever for congenital dislocation, was popularized by Margary. Its results left much to be desired, and the operation is seldom used at the present time. The author would only employ it if symptoms of coxitis developed in the dislocated joint, as occasionally happens later in life. Hoffa-Lorenz Operation. — The only operation to be considered at the present time is the open reduction of the dislocated head into the enlarged old cavity. The following description is of the operation as the author performs it at present with the best results: The patient, being prepared and anaesthetized, is placed in the semilateral position. An aseptic countertraction pad is placed against the perineum and traction made upon the limb by an assistant. In older patients extension is made with the Lorenz screw and cotton anklets. The head being drawn down and held at the level of the cavity, a 2.5-inch incision is made downward, beginning 0.25 inch from the upper anterior border of the great trochanter. (Fig. 253.) The Fig. 253. Incisions of Lorenz and Hoffa for open reduction. fascia lata is incised and in older children nicked transversely. The gluteus medius and minimus beneath are retracted upward and the capsule of the hip-joint exposed in its entire extent. The capsule is incised transversely, the extended limb being meanwhile rotated out- ward. If the ligamentum teres is present, it holds the head; it is first divided with the scissors close to the head, seized with a toothed forceps, pulled out, and divided at its attachment on the lower margin of the cavity. The head is thus fully exposed, and may be pushed aside and the entire cavity examined with the finger and excavated. The third part of the operation is the formation of the new cavity. The author uses various sized spoons with bayonet-shaped handles. Doyen's joint-drill is very useful. The new cavity should be deep and broad, and the walls should be fairly sheer, especially above, to give good support to the head. The last and most important step in the operation is the reduction of the head. In young children this is usually extremely easy; in older patients it is often very difficult. The hindrance lies to a great extent 414 MALFORMATIONS OF THE HIP-JOIST. in the soft parts; exceptionally it is the form of the head. The shortening of the soft parts is overcome by forced traction and thorough division of the anterior part of the capsule. Occasionally it will be necessary to nick the adductors with a tenotome or to divide the tendons in the popliteal space. If the hindrance is in the form of the head, it must be modelled to fit the cavity. The reduction itself will vary in individual cases, and must be experi- mented with. It may be effected by simple traction (especially in chil- dren), the head sliding in with an audible jerk; or it may be necessary to abduct strongly and rotate inward. Sometimes it is best to flex the limb at the hip and knee, then extend forcibly and rotate inward or outward with pressure upon the trochanter. If properly reduced, it should not be possible to force the head from the cavity by strong adduction or outward rotation. The author then packs the wound with sterile gauze, applies an aseptic gauze dressing and a plaster splint, the limb being held abducted and rotated inward by the assistant, while also maintaining extension and counterextension. The child is then placed in a Phelps bed. The first dressing remains from four to eight days. The author then removes the tampon and simply draws the wound together with a gauze roll. This is changed again at the end of eight days. The wound has generally healed in fourteen days after the first change of dressing, or at the most there are a few superficial granulating spots to be touched with silver nitrate or covered with adhesive strips. To prevent contractures and to mobilize the muscles of the entire limb, especially the hip muscles, energetic massage and electricity are applied daily with exercises, particularly abduction movements. If aseptic, the operation is without danger. In the author's last 100 cases, in which the muscles were protected carefully, he has not lost a patient. In regard to the results of the operation, it is impossible to restore* absolutely normal relations even by the most successful bloodless or open operation. What may be expected in unilateral dislocation is to overcome the shortening of the limb, to give the femur a firm support on the pelvis, and to restore the normal line of traction of the gluteals. Considering that the aim of treatment is essentially restoration of func- tion, the final results obtained by strengthening the muscles by massage and exercises may be designated as faultless in this respect. By inclin- ing the pelvis, the children compensate the slight shortening left, and finally walk so well that the unprejudiced observer will often have diffi- culty to determine which is the sound and which the operated limb. In bilateral dislocation the operation removes the deforming lordosis, diminishes the waddling gait to a minimum, restores the proper attitude of the limb, and improves the abduction. The earlier the children are operated upon, the better the final result. The best time for the operation, to the author's mind, is from the third to the eighth year. In general the tenth year is the limit of operability. Naturally it is not impossible that the operation may be successful at a later period, but the deformity, increasing with age, makes it impossible CONGENITAL DISLOCATION OF THE HIP JOINT. 415 to guarantee a complete result. Furthermore, the difficulty of reduction increases, and with it the possibility of infection. To repeat, therefore, the author would recommend that the operation should be limited to the tenth year. What shall he done for older patients? In the large material at the author's disposal he has often asked himself this question, and finally the study of the pathological anatomy led him to a method for the operation of old bilateral dislocation. He has performed the operation in a large number of cases with excellent functional results, the lordosis improving and the waddling gait disappearing partially or often completely. The following technic proved most serviceable: The joint is opened through a lateral incision, the soft parts are dissected off subperiosteally from the great trochanter, and the insertion of the capsule freed from the neck of the femur, so that the head can he freely luxated out of the wound. The head is removed close to the intertrochanteric line with a tenon-saw, the "funnel" of the capsule is then stretched tightly, and its posterior wall divided in the middle up to the ilium, its attachment on the acetabular margin divided, the adhesions separated, which always form between the capsule and the periosteum of the ilium, and the two flaps of the capsule excised. A free periosteal surface is thus obtained upon the ilium, against which the sawed surface of the femur is planted by abducting the thigh. After-treatment: iodoform gauze packing and extension or plaster splint. The patients become ambulant at the end of three months and w r ear the author's supporting corset described above. This method, which the author terms a pseudarthrosis operation, as he seeks to obtain fibrous union between the femur and pelvis, he can recommend with a clear conscience as excellent. Kirmisson was the first to propose subtrochanteric osteotomy for old unilateral dislocation. The author has repeatedly performed this operation as an oblique osteotomy in order to lengthen the limb by forcible extension, and has in fact obtained a lengthening of from 1.5 to 2 inches, and was well satisfied with the functional result. CHAPTER XXIII. INJURIES OF THE HIP. DISLOCATIONS OF THE HIP. The depth of the cavity, the strength of the capsule, and the power of resistance of the large muscles and of the neck of the femur, and the infrequent demands made upon the range of motion, are the reasons for the great infrequency of dislocations of the hip-joint. According to Kronlein, they stand below those of the shoulder and elbow in the list with a frequency of only 2 per cent. Well-developed men from the twentieth to the fiftieth year are most commonly affected, occasionally children, women, and old men. The left side appears to be injured somewhat more often than the right. According to Kneer, of 132 recent dislocations in v. Brims' clinic, 71 were in the left side, 59 in the right side, and 2 were double. Only 27 instances of double dislocation are known up to the present time. On account of its deep situation the articular head is not accessible to direct violence, so that dislocation is indirect. It is rarely produced by a simple blow upon the trochanter or a fall upon the bended knee or upon the feet. The cause is usually a violent and sudden exaggera- tion of an otherwise physiological movement, the femur being forced against the pelvis or the pelvis against the femur, as happens by falling from a great height or being run over by a heavy wagon, or by the impact of heavy bodies upon the hip-joint, as, for example, in being buried under a mass of earth or stone, etc. It is always necessary that the limit of motion should be reached and the greatest width of the head overreach the acetabular margin. The cartilaginous rim of the cavity and the check ligaments thus form a fulcrum against the neck of the femur, the femur representing the long or power arm, the head the short or weight arm of the lever. By the action of the long arm the head is forced in the opposite direction against the capsule, tears it, and slips out over the margin of the cavity. The head is therefore levered out of the cavity. It rarely remains partly in contact with the cavity to produce an incomplete dislocation. It is doubtful if this ever occurs. Once having left the cavity, it seldom retains its first position close to the acetabulum, but is impelled by the continuation of the force and the weight of the limb into a second position and held there by the uninjured part of the capsule, especially the iliofemoral ligament. The tension of the latter usually gives a typical position to the dislocated limb, so that, according to Bigelow, all dislo- cations are regular in which the ligament is intact, irregular in which (416) DISLOCA TIONS 01 THE HIP. 417 the ligament, the strongest in the body, is destroyed by extreme violence, ;i^, for example, machinery accidents. The head may leave the cavity behind, in front, above, or below, and the following dislocations are distinguished according to its position: 1. Dislocation backward (luxatio postica m- retrocotyloidea) : (a) iliac dislocation; (6) sciatic dislocation. 2. Dislocation forward (luxatio antica or precotyloidea : '/ supra- pubic I luxatio pubica or iliopectinea ; b infrapubic I luxatio obturatoria and luxatio perinealis . .:. Dislocation upward (luxatio supracotyloidea). 4. Dislocation downward (luxatio infracotyloidea). Dislocation backward is most frequent. Kneer'> compilation of the statistics of Cooper, Malgaigne, Weber, Hamilton. Billroth, and v. Brims gives among 210 dislocations 160 backward (70 per cent, and 49 forward 44 per cent.). Of backward dislocations, the iliac variety is more frequent than the sciatic (96 to 37, Kneer). The two varieties of forward dislocation are about equally frequent. Dislocation Backward. — The difference in position of the head in the two forms of backward dislocation is not great, but is important practically. The two forms may be considered together. Backward dislocation is generally caused by violence forcing the lower extremity into a position of flexion, adduction, and inward rotation. Whether the head lies above upon the ilium or below upon the ischium depends upon the degree of flexion and inward rotation; the action is either that the limb makes the abnormal movement, the pelvis being fixed, or the reverse. In the former case there are three possibilities: First, that the limb is adducted, rotated inward, and only slightly flexed. For example, the patient falls from a considerable height and strikes the ground with the foot gliding inward, or falls upon the side with the leg rotated inward. The force is thus transmitted to the head of the femur, which in turn is forced against the posterior-superior or posterior part of the capsule, and if the force is sufficient the latter is torn; the head passes through the capsule toward the ilium. The tear in the capsule always lies above the tendons of the obturators, which may also be torn. The head then lies either between the obturator interims and piriformis, the fleshy belly of the latter being lacerated or torn through, or the head passes beneath the pyriformis. the tendon of the muscle lying on the neck of the femur, the head resting upon the gluteus minimus, lacerated or torn from its insertion on the femur, and is covered by the edge of the gluteus medius and the gluteus maximus. I Fig. 2o4. 1 The iliofemoral ligament is put on the stretch chiefly in its outer arm; the anterior and inferior parts of the capsule are intact. I Fi^. 2-V>. The above mechanism is rare. As a rule, there is a more pronounced flexion — in fact, hyperflexion and strong inward rotation, the conditions under which the real lever action comes into play. It is rare that such dislocations are produced by merely falling on the ground; usually marked violence is necessary. The latter is most frequently applied as a heavy weight, which, as, for example, by the falling of a great mass Vol. Ill— 27 418 INJURIES OF THE HIP. of earth, transmits the rotary movement to the pelvis, the same being struck on the side opposite to, and being rotated forward toward, the side of the dislocation. The dislocation occurs similarly in railroad accidents, the patient being thrown out of the car and remaining sus- pended by the limb affected. In this case the cause is the weight of the body precipitated forward and rotated. In all these instances the mechanism is a lever action. By the strong flexion, adduction, and inward rotation, the head is forced against the posterior-inferior part of the capsule, the extremity becoming a two- armed lever, the fulcrum of which is the neck of the femur jammed against the upper-anterior margin of the cavity. The more the violence forces the long lever arm, the thigh, in the above direction, the more Fig. 254. Fig. 255. Position of the head in iliac dislocation. Position of the Y-ligament in iliac dislocation. (Bigelow.) the short arm forces the weight arm, the head, backward and downward against the capsule, till the latter finally yields. The tear in the capsule therefore lies at the posterior-inferior margin of the cavity. If the head protrudes, it does not remain behind and below the cavity, but rises backward and upward to a second position from the weight of the limb or the effort of the patient, but especially from the continuation of the force causing marked inward rotation of the thigh. The head now lies upon the inferior-posterior surface of the ischium between the acetabular margin and the lesser sciatic notch, pushing the tendons of the obturator internus and gemelli before it till they slide over it, and the tendon of the obturator internus is caught between the head and the rim of the acetabulum, the gemelli usually being torn. The head then lies between DISLOCATIONS OF THE III J'. 419 _■ the greater and lesser sciatic notch or at the lower part of the latter. It presents between the pyriformis muscle, covering it above, and the quadratus femoris, the latter being slightly torn. This is its position in ischiatic dislocation, which Bigelow calls "dislocation beneath the tendons/' on account of the above relation to the rendon of the obturator internus. Fig. 256. The tendon of the obturator interims prevents the head from rising higher, unless it is torn, which happens very seldom. According to the above statistics, the head is usually found higher upon the ilium, but never beyond an imaginary line drawn from the anterior-inferior -pine to the upper border of the greater sciatic notch. A higher position i- prevented chiefly by the tightly stretched inner arm of the Y-ligament and the i: posterior wall of the capsule. There- fore the iliac dislocation take- place in- directly and secondarily, the head hav- ing the same relation to the surrounding muscles as in the previously described direct dislocation, with the exception that the outward rotator- are torn. The dislocation, therefore, named according to its origin, is termed ilioischiatic. Various important practical patholo- gico-anatomical details should be men- tioned. There i- not infrequently a fracture of the acetabular margin at the point of exit of the head: the car- tilage may he loosened from the under- lying bone; there may be a star-shaped p osition of the head ^ ^^ dislocation- fracture of the floor of the cavity. The capsule may be torn triangularly or transversely from the margin or split longitudinally from the margin to the trochanter. The tear is very seldom at the insertion on the neck of the femur. Sometimes the entire posterior portion is separated from the margin. If the lateral portions are intact, they project in front of the head and are stretched tightly between the posterior margin of the cavity and the neck. The Y-ligament is never injured in the regular form, thus explain- ing its great significance in this dislocation in being able, alone, to hold the head in its false position. In the ischiatic variety its inner arm is stretched chiefly; in the iliac variety, mainly the outer arm. The ligamentum teres is usually ruptured, but may be torn out of the depres- sion on the head or torn off with a piece of the head. Braun recently described a specimen in which the fracture-line ran from above down- ward through the head of the femur, the fragment being still attached to the ligamentum teres. The sciatic nerve may lie pushed up. stretched, or torn by the neck of the femur. The gluteal vessels may be compressed 420 INJURIES OF THE HIP. Fig. 257. or torn. The muscles inserted on the anterior surface of the femur are stretched tightly, especially the iliopsoas, pectineus, and the adductors. As to complications: aside from severe injuries, such as fracture of the vertebrse or pelvis and injuries of the viscera, there is occasionally frac- ture of the neck of the femur or of the shaft, or bilateral dislocation, the latter to be described separately. Kammerer made a careful com- pilation in 1889 of 19 cases of fracture complicating all forms of hip dislocation. Of these, 13 were of the shaft of the femur, 6 of the neck; 12 accompanied backward dislocation, 2 downward and forward dislocation, and 5 forward and upward dislocation. Symptoms. — Picturing to one's self clearly the position of the head in iliac and ischiatic dislocation from a study of the above-mentioned points or of a prepared pelvis, and remembering that the head never ascends actually onto the surface of the ilium, it will be obvious at once that the two forms show no great clinical dif- ferences. In both cases the limb is flexed, ad- ducted, rotated inward, and shortened, the degree of dislocation alone distinguishing the two forms. In the iliac form (Fig. 257) the foot is rotated inward and supported upon the toes of the other foot if the patient stands. The flexion of the hip, which is always present, is compensated by the inclination of the pelvis and lateral curva- ture of the lumbar vertebrae until the sole of the foot touches the ground. In the dorsal recum- bent position the flexion is greater, the foot lying across the other ankle. In the ischiatic form the flexion and inward rotation are greater. In standing, the foot projects forward beyond the other and is brought to the ground with difficulty. Recumbent, the flexed knee crosses the other thigh, its inner border resting on the front of the latter above the patella. The shortening is ap- parent and real; apparent from the elevation of the pelvis in the effort to correct the adduction; real from the upward displacement of the head J) I on the pelvis, the tip of the trochanter being from W^^W? 0.75 to 2 inches above its normal position in iliac dislocation. (Bigei.w.) the Roser-Nelaton line. The lines connecting the anterior-superior spine, tuber ischii, and the great trochanter form a triangle, the apex pointing backward and up- ward. The distance from the anterior-superior spine to the tip of the internal malleolus is shortened, the shortening being greater in the iliac than in the ischiatic form. The deformity of the hip is equally striking. The hip is broader, the great trochanter rotated inward and forward, stretching the fascia lata outward. In lean subjects the hip is fuller, the gluteal fold higher. The head may be felt as a hard rounded body deep among the hip DISLOCATIONS OF THE Jlir. 421 muscles; in stout people it will be necessary to rotate the thigh to identify the head by its movements. The normal resistance is lacking in the groin; rarely the contour of the hip is entirely obliterated by subcu- taneous extravasation. The almost complete fixation of the head is (h\e to the action of the Y-ligament and intact part of the capsule. Passive abduction and outward rotation are impossible, flexion and adduction less so, active motion impossible. Extension and abduction are also impossible. There is an elastic resistance to all attempts at motion. In youthful patients there is not infrequently temporary retention of urine from the severe violence and concussion of the pelvis. The subjective symptoms are comparatively slight. The pain is intense, and compression of the sciatic nerve causes tingling and burning sen- sations radiating to the foot, or severe sciatica. In extremely rare cases the Y-ligament is torn and an irregular dislocation produced, the limb being rotated outward by its own weight. Diagnosis. — From the above the diagnosis is simple. Mistakes are hardly possible, although the condition may be confused w T ith contusion of the joint if there is much swelling, or with the rare fracture of the neck with inward rotation. The differential points will be discussed later. In all doubtful cases examination under anaesthesia will help. The flexion, adduction, and inward rotation are greater in the ischiatic than in the iliac form. Complicating fracture of the acetabular margin usually makes reduction easier, and may give crepitus; it favors a recurrence. Simultaneous fracture of the neck is very rare; the limb is shortened and rotated outward, and the head found beneath the gluteals. Prognosis. — Recent dislocations, properly handled, generally give a good prognosis; usually no derangement is left, habitual dislocation is extremely rare and only occurs with simultaneous fracture of the ace- tabular rim. Some weakness usually persists for from four to six weeks on account of the muscular atrophy and occasional pain. The loss in earning-efBciency of such a patient is estimated at about 25 per cent. The dislocation becomes old very soon, and although there are single in- stances in which reduction was possible after years, complete recovery is usually impossible at the end of a few weeks. The head generally forms a new joint for itself, often very complete. The shortening and inward rotation, however, are a great hindrance in walking, so that crutches are always necessary. Exceptionally the inward rotation diminishes in time, but the patients walk with a pronounced limp and tire easily. The limb is always more or less atrophic, and pressure of the dislocated head upon the sciatic nerve may produce continuous and annoying neuralgia. The old cavity fills in with fibrous tissue and in time is entirely oblit- erated, v. Volkmann found a strip of muscle over the cavity w T ith fibrous changes on its upper surface two months after dislocation; MacCormac saw a cavity entirely filled with fibrous tissue; Que'nu observed a new cavity and capsule of fibrocartilaginous consistence; Nicoladoni, a new strong dense capsule and a cavity covered in spots with fibrocartilage; Niehaus, a new capsule almost entirely ossified. The complete new 422 INJURIES OF THE HIP. formation of a ligamentum teres, as demonstrated experimentally and reported by R. Volkmann, is interesting. The head of the femur loses its normal form, is worn off where it articulates with the new cavity, and loses its cartilage elsewhere. The evil consequences, such as acute suppuration and putrefaction of the joint, resulting in former years from violent and rough reduction methods, are hardly to be feared at the present time. The etiology and anatomy of dislocations are so well known to-day that surgeons do not dread reduction like their predecessors. If done properly, it usually presents no difficulties. Fortunately the number of cases is few in which the rational procedure fails, and these are the cases in which there is an insurmountable hindrance to reduction: fragments of bone lodging in the cavity; the ligamentum teres may tear a fragment from the head and lie with it in the cavity; a piece of the acetabular margin may be broken off and be pushed into the cavity by the head every time reduction is attempted; a piece of the trochanter torn off with the capsule attached to it may be caught between the head and the cavity; a fragment of the cotyloid cartilage may be broken off from the bone and interposed between the head and the cavity. The head may be buttonholed through the outward rotators, but it is hardly conceivable that the hindrance cannot be overcome by the appropriate procedure. This cannot be said of the hindrance occasionally caused by tears in the capsule; the rent may be so narrow that the head pushes the capsule in front of it, as demonstrated beyond question by Gelle; or a torn portion of the capsule may lodge in the cavity and so prevent reduction. Treatment. — As reduction is painful and the large muscles Alive to be relaxed, anaesthesia is preferable. The fixation of the pelvis can be accomplished in two ways: either by pressure upon the anterior superior spine or by Gersuny's method. The latter consists in flexing the other limb at the knee and thigh and pressing the knee firmly against the chest while the operator manipulates the dislocated thigh with one hand upon the knee, the other at the ankle. Reduction is accomplished without violence or roughness by methods deduced from the study of the etiology and the pathological anatomy, and which may be termed anatomico- physiological procedures. There are only two methods which can lay claim to this name, and the author therefore only mentions these two: (1) the method of manipulation proposed by Roser, Busch, Bigelow, and Kocher, and in which the author follows Kocher; and (2) the lever method, recommended especially by Middeldorpf and used by other authors. Kocher's Method. — The thigh is first rotated inward still further, flexed to a right angle, direct traction exerted in the axis of the flexed thigh, and the limb then rotated outward and extended. The inward rotation relaxes the capsule and Y-ligament and lifts the head off from the posterior surface of the pelvis. Flexion to a right angle brings the head down behind the intact part of the capsule to opposite the tear. Inward rotation and adduction of the thigh are meanwhile maintained without using any force. One should avoid violent flexion, which may DISLOCATIONS OF THE HIP. 423 draw the head forward over the lower margin of the cavity and produce a dislocation forward upon the obturator foramen. The traction upward puts the Y-ligament and the capsule, chiefly its posterior part, on the stretch and lifts the head to the level of the acetabular margin, the trochanter being fixed by the tension of the Y-ligament, and the outward rotation then forces the head into the cavity. Middeldorpf's Leveb Method. — The movements are strong flexion, abduction, and rotation outward. Flexion levers the head away from the pelvis and brings it opposite to the tear in the capsule; abduc- tion makes tense the outer limb of the iliofemoral ligament and presses the neck of the femur or the trochanter against the edge of the cavity, and on this fulcrum the outward rotation, following, levers the head into the cavity. In both methods there is a characteristic sound as the head slips into the cavity. Motion is then free in all directions. The beginner should be careful not to produce an obturator dislocation. Both methods are equally good and practicable. The second is particularly useful for older injuries, but great care should be exercised in abducting and rotating outward not to fracture the neck, a possibility, especially in the aged, which has happened to the best surgeons. It may be avoided by carrying out all movements slowly and steadily, not by jerks. If reduction is impossible and one is obliged to conclude that there is an insurmountable hindrance, as mentioned, the attempt should be abandoned unless an open reduction can be performed with aseptic precautions, as accomplished successfully by v. Volkmann. Recent dis- locations complicated by fracture of the neck or of the shaft, if non- reducible, require operation. If on exposing the hip-joint for fracture of the neck reduction of the head is impossible, the experienced "Asep- tiker" may resect the head, place the end of the shaft in the cavity, and with the limb abducted apply an adhesive plaster extension splint with weights. The less experienced should attempt to secure union of the fracture in the most favorable position and the formation of a new joint. One may try to reduce old dislocations by the lever method, after dividing the adhesions as much as possible, by rotating. If operation is necessary: after dividing all shortened soft parts, removing all interposed ligaments, and exposing and cleaning out the old cavity, the head is replaced. This has been successful in a number of cases. (R. v. Volk- mann, Drehmann, Endlich, and Payr.) Another method is to obtain a new joint, and later restore the proper attitude of the limb by sub- trochanteric osteotomy. Hoffa's oblique osteotomy is most advisable, as the false position of the limb can thus be compensated and the shortening overcome at the same time to a great extent. Resection of the head of the femur should be done only as a last resort in stubborn cases. So far it has been performed in 18 cases, according to Kirn, Bloch, and Ostermayer, with 13 recoveries, and in part with excellent functional results. If one is unfortunate enough to fracture the neck in attempting the reduction of old dislocations, if the 424 INJURIES OF THE HIP. Fig. 25S. fracture is extracapsular an extension splint should be applied; if intra- capsular, removal of the head is indicated, as experience has taught that the head easily becomes necrotic on account of its poor blood-supply. The after-treatment consists in applying an ice-bag to the hip and immobilizing for a short period — two to three weeks if uncomplicated, six weeks if there is a fracture of the acetabular margin — otherwise recurrence takes place easily. After the patient is about, massage, electricity, and careful exercise should follow. Dislocation Forward. — Whereas backward dislocation results from violence flexing, adducting, and rotating the thigh inward, forward dislocation results from violence abducting and rotating the thigh outward while it is flexed or extended. The abnormal movement may be on the part of the pelvis or the thigh. The tear in the capsule through which the head emerges is either at the anterior-superior or anterior- inferior margin of the cavity, and the head comes to lie upon the corresponding surface of the os pubis. Suprapubic Dislocation. — The cause of pubic dislocations is rarely direct vio- lence, but usually some force bending the body backward while the thighs are ab- ducted and rotated outward, as, for ex- ample, in children, a "blow from a swing pushing the body backward ; similarly in adults by the descent of a heavy body upon the chest, or by being caught in the spokes of a wheel, or doubled back- ward in wrestling, catching the foot in a hole in walking or running, the body being bent backward to check the fall. In every case it is a lever action. The neck of the femur is pressed against the fulcrum established by the lower back margin of the cavity. The head, the weight lever arm, is forced forward and upward against the capsule and tears it at its weak part in front of and to the inner side of the iliofemoral ligament. The position of the head upon the os pubis may vary, but is most frequently upon the pubic spine to the inner side of the anterior-inferior spine at the point of junction of the ilium and the horizontal ramus of the os pubis, the iliopectineal eminence. If it lies a little more outward directly beneath the spine, it is termed a luxatio subspinosa; if it lies more in the middle of the pubic bone or farther to the inner side of the pubic spine, it is a pubic dislocation. In regard to the pathologico-anatomical details: The head is held firmly against the bone by the pressure of the iliopsoas and tense fascia Suprapubic dislocal ion. DISLOCATIONS OF THE HIP. 425 lata running over it or over its neck. (Fig. 258.) It presses slightly against the groin at the internal ring. The great trochanter lies in the acetabulum. Lauenstein in one instance on autopsy found the great trochanter torn off by muscular traction; in this case the neck was supported against the upper margin of the cavity. The capsule either tears close to the neck, the torn flap attached to the acetabular margin being forced into the cavity, or it is torn off directly in front close to its marginal attachment so that the neck is buttonholed between the capsule and the cartilage. The Y-ligament is intact, the inner arm less tense than the outer, the latter being pulled backward with the great trochanter toward the cavity. (Fig. 259.) The crural nerve runs over the neck; Fig. 259. Fig. 200. Pubic dislocation. Pubic dislocation. (Bigelow.) the femoral vessels are displaced inward toward the symphysis. The artery lying between the head and the os pubis may be compressed. Rarely the large vessels lie over the arch of the head and are naturally stretched severely. The pectineus is usually torn laterally or pushed and bent toward the symphysis; the three gluteals are relaxed, their insertion drawn inward with the trochanter. The outward rotators together with the back part of the capsule are displaced inward, forced into the cavity by the trochanter, and either greatly stretched or torn with the exception of the obturator externus. Symptoms. — The symptoms are significant. (Fig. 260.) The thigh is usually extended, abducted, and rotated outward. The abduction is least in the iliopectineal form, the thigh being almost parallel to the 426 INJURIES OF THE HIP. other. The more the head approaches the middle line, the more marked are the abduction and the flexion. If the flexion is not noticed at first, it is because it is corrected by the inclination of the pelvis. The short- ening is always real, the head lying above the cavity, although the limb may appear to be lengthened on account of the abduction. Beneath Poupart's ligament, near the anterior-inferior spine or the pubic spine, can be felt the rounded prominence of the head, verified by rotation. To its inner side lies the femoral artery; the latter lies partially upon the head and transmits a distinct thrill to the finger. Active motion is impossible; passively flexion, adduction, and inward rotation are also impossible; abduction and outward rotation are possible to a very slight extent on account of the support of the tense intact back part of the capsule and the inner arm of the Y-ligament. Walking is sometimes possible, apparently because the neck is supported by the iliofemoral ligament and the head against the anterior-inferior spine. If the crural nerve is stretched, there may be intense pain radiating into the thigh, or numbness, or a feeling of heaviness. Occasionally there is retention of urine. The hip is flattened and the gluteal fold obliterated. The normal prominence of the trochanter is absent. The dislocation may be mis- taken for fracture of the neck, but not if the differential points to be given later are compared. Prognosis. — The prognosis is relatively the best of all dislocations of the hip. Neuralgic pains in the crural nerve may persist for some time after reduction. Even if unreduced the use of the limb may be recovered if a new joint is formed on the pubic bone or the head is supported against the inferior spine. Flexion at the hip and knee is usually lost or diminished on account of the interference with the function of the flexors of the leg arising from the tuber ischii. Treatment. — Kocher's Method. — The thigh is hyperextended, flexed, with pressure upon the head, and rotated inward. By hyperex- tension the head is lifted off the bone in case the outward rotation and abduction are marked. The femur forms a lever, the shaft being the long arm, the neck and head the short arm, the fulcrum the trochanter held by the intact portion of the capsule. The head having been freed, is pushed by direct pressure toward the cavity to prevent it from sliding upward as the iliofemoral ligament is relaxed in flexing. Flexion is continued to a right angle; the lower back part of the capsule is thus put on the stretch and the head rotated inward into the cavity. Middeldorpf's Lever Method. — It consists in hyperextension, strong flexion, adduction, and inward rotation. The purpose of hyper- extension is as above. Flexion is carried to an acute angle; the head thus slides downward upon the upper margin of the cavity. Adduction brings the neck against the margin of the cavity, and upon this fulcrum the head is levered into the cavity by inward rotation. In both methods the patient lies at the edge of the table to permit of hyperextension . Infrapubic Dislocation. — Abduction and outward rotation of the thigh are essential for the production of this dislocation. If the thigh is DISLOCATIONS OF THE 11 IP. 427 abducted and rotated outward, a simple blow from the side is sufficient to force the head over the front margin of the cavity. Such direct violence is rare; usually the thigh is flexed strongly and permits of the lever action. The thigh is abducted, rotated outward, and flexed; the upper outer margin of the acetabulum forms a fulcrum; the head is forced against the front lower part of the capsule, tears it, and advances directly to the obturator foramen (obturator dislocation). If the flexion is pronounced, the head may descend to the ramus of the ischium and lie upon the perineum (perineal dislocation). If the violence produces inward rotation instead of abduction and outward rotation at the moment when the head of the strongly flexed limb lies at the projecting Fig. 201. Fig. 262. Obturator dislocation. (Bigelow.) border of the ischium, the head may glide backward along the lower margin of the cavity to the ischium (ischiatic dislocation). The author has seen that the reverse process can occur in reducing a backward dislocation, the head being pushed forward by flexing too strongly, producing a secondary obturator dislocation. The causes are numerous: a heavy weight falling upon the back while the body is bent forward and the thighs abducted; a fall from a height with the thighs spread; from the thigh being held between girders, while the body falls laterally; a fall from a horse with the foot caught in the stirrup, etc. The head lies upon the obturator foramen (Fig. 261 ) usually at the lower part, covering about one-half or two-thirds of the membrane. 428 IS JURIES OF THE HIP. It may compress the obturator vessels and nerve; sometimes the external obturator muscle lies under the head, but is usually stretched tightly over it with the adductor longus and brevis and may be torn. The lower part of the head rests upon the upper part of the adductor magnus. The posterior surface of the great trochanter lies directly in the cavity and pulls the attached gluteals inward. The front upper part of the capsule is always intact and stretched over the neck, preventing the head from rising and forming a suprapubic dislocation. This front upper part of the capsule with the iliofemoral ligament gives the limb its typical atti- tude. The back part of the capsule is not tense. The Y-ligament is stretched tightly. (Fig. 2G1.) Its inner arm rotates the femur outward and is rarely torn. In the latter event the outward rotation is less. In perineal dislocation the tear in the capsule is usually larger. In a speci- men of Bigelow's the outer arm of the Y-ligament was also torn; the femoral vessels ran over the neck with the crural nerve; the pectineus and adductor brevis lay between the neck and the ischium. Symptoms. — The characteristic symptoms of obturator dislocation are moderate flexion (about 35 degrees), abduction, outward rotation, and shortening (Fig. 262) ; they are more distinct if the patient is recumbent. The limb is then abducted, flexed at the hip and knee, is supported upon the outer border of the foot and is shortened. If the patient stands, flexion is less pronounced as the spine curves forward and the pelvis inclines forward and to the side, thus compensating the abduction. The limb therefore appears lengthened, but is actually shortened. It has been repeatedly conceived that the limb must be lengthened in that the head is lower on the obturator foramen than in its cavity. Careful measurements from the anterior superior spine to the tip of the external malleolus verify the shortening. Malgaigne found a shortening of 7 lines; Treub, 1^ inches; Lauenstein, 2 inches. The outward rotation may be masked by the inward rotation of the foot. (Fig. 262.) The patient turns the foot forward, with the toes upon the ground, the heel elevated, the knee flexed, and the hip-joint abducted and rotated outward, the abduction and flexion being propor- tional to the lowness of the head. The buttock is flattened, the normal prominence of the trochanter is lacking, and the hip is widened and fixed. Motion is impossible with the exception of perhaps slight abduc- tion and flexion. The head produces slight bulging of the soft parts in the region of the falciform fold of the fascia lata, and can be recognized if the adductors are not too strongly developed. One often feels merely an indistinct sense of something rolling in rotating the thigh. The head can always be felt distinctly per rectum. The patient is often able to walk some distance after the injury, apparently because the head obtains a good support against the obturator foramen and the intact upper part of the capsule. Pressure upon the obturator and crural nerves often causes intense pain or at least numbness in the limb. Perineal dislocation has so far been seen only 9 times. (J. Riedinger, 1892.) It is easily recognized. (Fig. 263.) The limb is in a position of maximal abduction and maximal flexion, the former being dependent DISLOCATIONS OF THE II IP. 429 Perineal dislocation. (Bipelow.) upon the latter on account of the check action of the iliofemoral ligament. The thigh is almost at a right angle to the body. The leg, flexed sharply, rests upon the outer border of the foot. It is impossible to stand erect upon both feet, as the pelvis cannot compensate the deformity. The head can he felt distinctly projecting behind the scrotum or beneath the adductors. The differentia] diagnosis of obturator dislocations from fracture of the neck will be mentioned later. Prognosis. — The prognosis of unreduced obturator dislocations is not unfavorable. The head forms a good nearthrosis in its new position and the patient may walk very well. The head is gradually pushed up- l' I<; - 2G 3. ward by the body-weight and the limb assumes an attitude similar to that in suprapubic dislocation; the knee is hyperextended to make both limbs of the same length : otherwise the dislocation is the same as the pubic form. Treatment. — Kocher's Ra- tional Mkthod. — Flexion to a right angle, vertical traction in this position, and strong outward rota- tion. Flexion is necessary to relax the iliofemoral ligament. If the thigh is flexed to a right angle, no part of the capsule is tense. To utilize the tension of the back part of the capsule in order to rotate about a fixed point, traction is now exerted vertically. By rotating the thigh forcibly outward the posterior part of the capsule is twisted and shortened, the outer arm of the Y-ligament is put on the stretch, and the head is drawn upward and backward into the cavity. The perineal dislocation can often be reduced by simple downward traction combined with strong outward traction on the upper part of the thigh. Middeldorpf's Lever Method. — Flexion to a right angle, adduc- tion, and inward rotation. Flexing the thigh in the given position relaxes the capsule and the Y-ligament and frees the head. In order to prevent the head meanwhile or during subsequent adduction from sliding around outside of the cavity and producing an ischiatic dislocation, the limb is drawn upward at the same time by means of a sling. Adduction brings the head to the cavity, inward rotation levers it in. For the treatment of complications and old dislocations see under Backward Dislocations. Dislocation Downward. — Dislocation directly beneath the acetabu- lum is very rare. The tear in the capsule is in its lower pole. The upper surface of the head lies upon the tuber ischii, supported in front and to the inner side by the tense adductors; behind, by the equally tense flexors of the knee. The iliopsoas, pectineus, and Y-ligament are also stretched tightlv. The dislocation is caused by forced abduction without rotation of the thigh, occasionally by a direct blow from above 430 INJURIES OF THE HIP. Fig. 264. upon the flexed thigh. As the head is not supported by the tuber ischii, ir passes readily into a second position, ischiatic dislocation, by abduction and inward rotation, and by adduction and outward rotation to an obturator dislocation. Occasionally it becomes subcotyloid instead of ischiatic or obturator. Symptoms. — In the regular form with the Y-ligament intact the symptoms are unmistakable. (Fig. 264.) The thigh is flexed not quite to a right angle, also the knee, so that the leg hangs against the thigh. The thigh can be easily abducted and rotated outward; extension is impossible; the other movements are less extensive; rotation is freest. It is not always possible to feel the head on account of the overhang muscles. The irregular dislocation which is accompanied by lacera- tion of the Y-ligament gives an atypical attitude; the thigh may be extended, rotated inward or outward, or abducted. Prognosis. — The prognosis is favorable as reduction is easy. In irreducible irregular dislocation the head may be supported beneath the acetabulum and motion be possible. Treatment. — Reduction is by simple traction in the given direction of the thigh — namely, of flexion and abduction, and finally outward rotation. Dislocation Upward. — Dislocation up- ward is rare, but more frequent than dis- location forward. We are indebted to Blasius for a comprehensive monograph based on 23 cases of upward disloca- tion. The head lies either upon the an- terior-inferior spine or below it, or between it and the anterior-superior spine. (Fig. 265.) The cause is flexion, adduction, and outward rota- tion, and the dislocation is therefore to be regarded as a variety of iliac dislocation, except that the final motion is outward instead of inward rotation. The capsule is torn at the posterior margin of the cavity. The Y-ligament is in front of the head and its outer arm is stretched tightly. Symptoms. — The symptoms may be mistaken on superficial examina- tion for those of iliopectineal dislocation. The limb is extended, adducted, rotated strongly outward, and shortened. (Fig. 266.) The head can be felt beneath the anterior-superior spine. The shortening appears greater on account of the adduction. Although adduction may be sometimes less marked, outward rotation is always so pronounced that the foot points sideways or even backward. According to the degree of outward rotation, the great trochanter is displaced either backward or more to the side, and the normal site of the trochanter is accordingly depressed or more prominent. The axis of the femur is apparently displaced laterally, giving a curved outline to the inner surface of the Subcotyloid dislocation. (Bigelow.) DISLOCATIONS OF THE ll u: 431 upper pari of the thigh. The buttock is relaxed, broad, and flat, the fold elevated. At the junction of the hip with the groin and perineum there are several small very distinct folds of skin. Flexion is possible, to a slight extent; all other movements impossible. Scriba describes a subvariety of this dislocation — luxatio intrapelvica — in which the head could be distinctly felt through the abdominal wall above the iliopectineal line, the neck in the iliac fossa, the great trochan- ter on the outer portion of the horizontal ramus of the pubis, on the anterior-inferior spine. The thigh was flexed, adducted, and rotated inward. The dislocation was caused by a blow upon the chest from a swing. By hyperextension the dislocation was transformed into an iliopectineal dislocation and thus reduced. Fig. 2G">. Fig. 266. Supracotyloid or supraspinous dislocation. (Bijrelow.) Prognosis. — The prognosis of upward dislocation is favorable as reduc- tion is easy. Old dislocations permit of good function as the head is supported against the anterior-superior spine. Treatment. — Reduction is by moderate flexion, adduction, downward traction, and inward rotation. Central Dislocation. — By central dislocation is understood an intra- pelvic displacement of the head through the fractured acetabulum. It is caused by severe violence crushing the floor of the cavity and com- pletely tearing the capsule. There are usually other complicating fractures of the pelvis or injuries of the intestines. 432 INJURIES OF THE HIP. Fig. 267. Symptoms. — The symptoms are shortening of the limb, outward rotation, and fixation. The shortening is overcome by strong traction, but returns immediately. Katz reports 11 cases, 6 of which died. Diagnosis. — The diagnosis is made from the ease with which the shortening is overcome, the immediate return of the latter on releasing the limb, by rectal examination, and the away. Treatment. — The treatment consists in reducing and applying an extension splint. Bilateral Dislocations of the Hip-joint. — In 1887 Niehaus collected the 26 cases of simultaneous dislocation of both hip-joints seen up to that time. Since then a case of Niehaus' and 2 from the clinics of P. v. Brims and Schonborn, bring the number up to 29. Among these there were 4 forward dislocations (obturator), 6 backward, and the others were partly backward or partly forward. The cause was either the impact of a heavy body or blows forc- ing the body violently backward or forward. The hip-joints were thus hyperextended or hyperflexed. Symptoms. — The symptoms were usually very clear. Fig. 267 shows a bilateral backward dislocation in which there was pronounced promi- nence of the trochanters and lordosis. The striking feature of the bilateral forward dislocation is the marked abduction of the limbs. In Ebner's case the knees were 6 inches apart. Diagnosis. — The diagnosis is not always made immediately. Often the dislocation is reduced on one side and the other recognized by the fact that the limbs are not parallel. In Niehaus' case there was considerable swelling about the pelvis, which was regarded as an indication of bilateral fracture of the neck. Prognosis. — The prognosis is relatively good. In the above 29 cases reduction and recovery occurred in 21, 4 remained unreduced, 1 patient died from the operation for resection of the head, another in shock. Treatment. — Reduction of one dislocation after the other is to be performed as described previously. Voluntary Dislocation. — It is noteworthy that voluntary dislocation is rather frequent in the hip. Perrin collected 15 cases, Hamilton 6 from English and American literature. Kronlein cites cases of Portal, Humbert and Jacquier, Stanley, Karpinski, and Peininger, 5 in all. Burd, Adams, and Macleod have each published a case. Karpinski's Bilateral dislocation. (After Niehaus.) FRACTURES OF THE UPPER ESI) OF THE FEMUR. 433 case was very typical. A well-developed man, twenty-one years old, had sustained a dislocation of the left hi]) five years previously. All movements of the joint in walking were free, but in addition the patient could dislocate the head of the femur backward into the outer cavity of the ilium with a loud snap by placing the weight of the body on the left leg and rotating the body to the left. The head could be felt distinctly. The great trochanter stood some distance above the Roser-Nelaton line. By simply contracting the hip muscles he could reduce the dislocation without further aid. As Pitha has said rightly, voluntary dislocation is a trick, the patients learning to control the individual muscles favoring the dislocation. By constant practice it is possible to learn to dislocate many joints voluntarily; for example, Macleod's case, the American athlete Warren, could dislocate and reduce almost all his large joints voluntarily. A secondary dilatation of the capsule goes hand in hand with the training of the muscles; that is the only thing found so far in autopsies. A congenital anomaly of the joint or a congenital defect of the joint-surfaces can be excluded, as the dislocation does not occur involuntarily as it does in habitual dislocations. Previous trauma is often stated as the cause. Trauma, however, can only be the predis- posing cause in directing the attention of the patient to the joint. Vol- untary dislocation causes no harm, and therefore does not require treatment. FRACTURES OF THE UPPER END OF THE FEMUR. Anatomy and Physiology. — The articular head of the femur is sepa- rated from the shaft by a long neck, at the base of which are two trochanters, muscular tuberosities, much more strongly developed than in the humerus. The neck is attached to the shaft at an angle, so that the great trochanter represents the upper end of the shaft. According to an earlier view generally accepted, the angle between the neck and shaft was supposed to be more acute in women than in men, namely, more of a right angle. This is not the case. Sharpey's recent inves- tigations show that the angle is the same in adults and elderly indi- viduals, men and women, and only about 2 degrees wider in children. It is usually about 127 degrees, varying between 115 and 140 degrees. It is smaller after rhachitis. The head develops from a separate epiphysis, the line of which corre- sponds to the articular margin. The trochanters each have a separate primary centre; on the other hand, the condyles have a common epiphysis the line of which still exists in the eighteenth or twentieth year, running in front above the trochlea, at the sides above the epicondyles, and behind along the linea poplitea. The femur has to bear the entire weight of the body in the upright position. The power of resistance or a bone is naturally decreased considerably by any inflexion in its axis, and this is the case in the femur from the angular deviation of the neck. This would therefore be the weakest part of the bone if nature had not fitted it for its burden by a particular construction. The neck, in addi- Vol. III.— 28 4:j4 INJURIES OF THE HIP. tion to being arched, is more convex on its posterior surface than on the anterior and longer; further, it is wedge-shaped, the sharp edge directed downward. It is thicker from above downward than from before backward. A prominent ridge run- from its inner circumference to the great trochanter. The compact substance is strongest where the greatest weight is carried. That portion corresponding to the inner lower part of the neck is called Adams' arch. Further strength is given by a compact ridge of bone projecting at the level of the lesser trochanter toward the middle line, penetrating \ inch into the spongiosa and dis- appearing immediately beneath the head on the anterior surface of the neck | Bigelow's septum, Merkel's Schenkelsporn, calcar femorale). To a certain extent it supports the Lesser trochanter; from it the spongiosa radiates fan-shaped toward the outer and especially the posterior surface of the great trochanter. The strength of the neck is dependent par- ticularly upon the structure and arrangement of the spongiosa. We are indebted to Culmann the mathematician, v. Meyer the anatomist, and the surgeons Packard, J. Wolff, Heppner, and Riedinger for a clear insight into this wonderful production of nature. These authors have shown that in its construction the spongiosa corresponds to the statical lines of pressure and tension. It is built as one would construct a bone mathematically to carry weights. In detail the lamellae can be separated into distinct systems, especially in thin sections, the Packard-Meyer 1 i lie-— running through the neck and recurring with great regularity. This arrangement of the spongiosa is only interrupted at places by the nutrient vessels of the neck dipping down into the bone. The head receives its blood-supply in youth through the vessels transmitted through the ligamentum teres; later in life these vessels disappear for the most part. (Langer. Senn.) The nutrition of the head is then supplied by the spongiosa of the neck. According to P. v. Brans' statistics, the frequency of fractures of the femur is represented by 6 per cent., of which a fourth part applies to the neck, the fracture- of which occur chiefly in old age. Fractures of the upper end of the femur include: 1 those of the head. (2) of the neck, 3 of the great trochanter, 4 and in the epiphyseal line. Fracture of the Head of the Femur. — Dupuytren states that com- pression-fracture of the head not infrequently results from falling upon the feet or upon the great trochanter, and that it is apt to be treated as a contusion of the hip-joint. Evidence for this statement has never been brought forward, nor are there any specimens of this sort. The only authentic case of fracture of the head is reported by Riedel. A fifteen- ■ >ld boy was run over by a heavy wagon. There was an actual shortening of 2 inches in the affected limb; it was flexed and rotated inward a- in the usual iliac dislocation. On passive motion the elastic resistance was lacking, however, and an indistinct crepitus could, be felt. After incising at the point of injury and removing the great tro- chanter the head and neck were found to be split longitudinally. Both fragments lay outside of the joint-cavity, the upper posterior margin of which was indented. Riedel conceived that the head was first forced FRACTURES OF I ill UPPER END OF THE FEMUR. 435 againsl the posterior margin of the cavity; at the moment in which it rested on the margin that it was struck by a second force and >plit into two pieces upon the sharp margin. The upper outer fragment was removed and the rest of the head returned to the cavity. Recovery followed with complete ankylosis of the joint and 1 inch shortening. Fracture of the Neck of the Femur. — In children and in men in the prime of life fracture of the neck is rather rare. It is more frequent after the fiftieth year, and after the seventieth year constitutes a third of the fractures. The fact that its frequency increases with age is easily explained by the changes occurring with age in the bone. Jt has been seen that in the prime of life on account of the peculiar form and anatomical structure of the neck it is aide to carry the weight of the body and resisl external violence. This is true up to the fiftieth year; then the changes gradually take place which affect the entire skeleton, namely, the senile osteoporosis, an eccentric atrophy of the bone. The cortex, especially in Adams' arch, becomes thinner and thinner. Many of the lamellae of the spongiosa are absorbed and are replaced by large cavities filled with yellow marrow. The calcar femorale disappears largely; the angle between the neck and shaft approaches a right angle. All the conditions which formerly gave the neck its power of resistance are lost, and more especially in women than in men; so fracture is more frequent . in the former than in the latter. Often very little force is required to ^ break the neck of the femur; so the cause is frequently stated to be not only a fall upon the feet, the knees, the buttock, or a blow against the outer part of the hip, but even a misstep or stumbling, accompanied by a forcible effort to maintain an upright position. The neck is apt to break in one of two places: at its junction with the head or at the base, its attachment to the trochanter. The fracture is intracapsular or extracapsular according, in its relation to the capsule, as it is near the head or at the base. The so-called mixed fracture is usually intracapsular in front, extracapsular behind, as the capsule in the latter place extends only to about the middle of the neck. The experience has been that a fall upon the foot or knee, namely, force applied in the long axis of the femur, usually causes fractures near the head, and that force applied on the outer side of the trochanter, namely, in the long axis of the neck, produces fracture near the trochanter. Further information is given by numerous experiments. (Heppner, Streubel. Riedinger, Rodet, Lardy, Mermillod.) Force applied in a vertical direction — that is, to the thigh through the foot or knee — produced oblique fracture of the neck near the head or more toward the middle. Applied to the trochanter from the side, it produced impacted fracture of the neck at its base or impacted fracture of the anatomical neck with much splintering. From before backward, it produced transverse intracapsular fractures. By forcibly rotating the thigh, Lardy once produced incomplete impacted fracture. Fracture also results from muscular action exaggerating the physio- logical movements of the hip-joint or from lifting heavy weights, which is also an indirect muscular action, the muscles transmitting the 436 INJURIES OF THE HIP. pressure to the neck. The tear fractures of the neck produced by the ligament of Bertin, for our knowledge of which we are indebted to Linhart and Riedinger, are especially interesting: in stumbling or slipping the body is thrown backward quickly to check the fall; the hyperextension of the hip-joint tightens the iliofemoral ligament, and the latter by reason of its greater strength tears the neck from its base. The fracture is always purely extracapsular; the fracture-line in front is clean, behind jagged; the Y-ligament remains attached to the neck. Pathological Anatomy. — The occurrence of incomplete fracture of the neck — infraction — has been known for a long while. (Colles, Adams.) Recently Kdnig has again called attention to it. It is almost always purely intracapsular; in only 2 instances was the fracture-line partly within and partly without the joint. Infraction may occur above, below, or behind in the neck (Figs. 268 and 269), the cortex on the other side Fig. 268. Fig. 269. Lac implete fractures of the neck. (Konig.) being more or less intact; sometimes there is no displacement; in other instances the head is bent downward, backward, or upward, the neck being impacted in the spongiosa of the head. This inflexion presupposes a certain amount of pliability in the intact cortex, which in turn is due to rarefaction of the bone caused by eccentric atrophy. (P. v. Brims.) Infraction is caused by diminished violence, either by the weight of the body alone or by a force partially spent in producing other injuries; so fracture of the great trochanter or of the shaft are found with the infraction. The diagnosis of infraction in anatomical specimens is to be given guardedly, as healed complete impacted fractures have the same appearance. Complete fracture of the neck is intracapsular, extracapsular, or mixed, any of which may be impacted. The relative frequency of intracapsular and extracapsular fracture has been a matter of consider- able discussion; Malgaigne regards the former as more frequent. This is apparently not so, however; according to Senn's recent statistics, they FRACTURES OF THE UPPER END OF THE FEMUR. ■;:]- are about equally frequent, 1 •">•'» intracapsular to 1~>7 extracapsular — but pure extra-articular fractures are a great rarity, the so-called extracap- sular fractures being usually mixed. Subperiosteal fractures occur occasionally; the capsule may be intact, but usually both periosteum and capsule are torn slightly. Intracapsular fractures are more frequently oblique than transverse, and occur at the junction of the head and neck, the thinnest pail of the neck (Fig. 270, fractura subcapitalis, Kocher). Sometimes part of the head is broken off. The fracture surfaces are usually serrated, rarely splintered; they may be free or impacted; if free and the capsule is intact, there is no displacement; if the capsule is not intact, the trochan- teric part of the neck is lifted by the elastic retraction of the muscles inserted on the great trochanter. The trochanter thus approaches the crest of the ilium, and is checked either by the resistance of the uninjured Fig. 270. Fig. 271. Impacted subcapital fractures. part of the capsule or by the abutment of the lesser trochanter against the inner fragment. If impaction occurs, the lower posterior portion of the cortex of the outer fragment is wedged into the spongiosa of the head ; there is not necessarily any great displacement. (Fig. 271.) Usually, however, the head is rotated inward and inclined so far backward that it touches the posterior intertrochanteric line. (Fig. 272.) The serra- tions in the anterior part of the fracture-line then interlock. The lower part of the neck is occasionally forced into the spongiosa of the head so that the upper part overrides the joint surface. (Fig. 273.) In childhood and youth intracapsular fracture occasionally occurs as a separation of the epiphysis between the head and neck. Extracapsular fractures may run in various directions: along the intertrochanteric line, ending near the lesser trochanter or directly beneath it (Fig. 274, fractura intertrochanterica, Kocher); or the line may run obliquely through the trochanters (fractura pertrochanterica, 438 INJURIES OF THE HIP. Kocher). The above forms are very frequently combined to produce Kocher's Y, I, or L fracture " ZertriimmerUngsbruch, Pels-Leusden "). In this case, in addition to the fracture of the neck, a second fracture-line Fig. 272 Fig. 273. Impacted fracture? of the neck. 'After I Comminuted fracture of the upper end of the femur. runs horizontally through the great trochanter above the lesser tro- chanter; or the great trochanter is broken into several pieces. I Fig. 27"). ) Very rarely the splintering involves the neck. The great trochanter is 1 i ,. 276. Impacted extracapsular fractures. 'After L - most frequently broken off in the form of a long quadrilateral in the portion bounded by the posterior intertrochanteric line. This quadri- lateral is longer if the lesser trochanter is involved, which, according to Riedinger, is the more frequent occurrence. The lesser trochanter may FRACTURES OF THE UPPER END OF THE FEMUR. 439 be broken off separately. (Linhart.) The variations in these fractures are numerous; Beimel recently classified thirteen types. The large majority of cases of extracapsular fracture are impacted, the impaction being complete or incomplete. In the less frequent incomplete form one side, usually the hack or lower part of the neck, is impacted in the trochanter. (Fig. 270.) If complete, the epiphyseal fragmenl and neck are driven deeply into the spongiosa of the trochan- teric portion. (Fig. 277.) The pointed fragment of Adams' arch is also forced deeply into the crushed hone. (Fig. 278.) The great trochanter is twisted backward, approaches the head, and the shaft of the femur is rotated outward. In exceptional cases the shaft is rotated inward, so that the neck is shorter in front than behind. The angle between the shaft and neck usually approaches a right angle, although it may be more obtuse. In the absence of impaction displacement is Fig. 277. Fig. 278. Impacted extracapsular fracture of the neck. (After Lessen.) always marked. As the capsule does not hinder the elastic retraction of the muscles inserted into the lower fragment from coming into full play, the shaft of the femur is drawn up above and behind the fragment of the neck by the action of the gluteals and the rectus femoris in front and the biceps, semitendinosus and semimembranosus behind. At the same time the lower fragment (the shaft) is apt to be rotated outward by the weight of the limb, as will be explained later. Symptoms. — It is impossible to locate fractures of the neck accurately on account of the shortness of the fragment and its deep situation beneath the firm tissues. In practice it is most important to determine whether the fracture is free or impacted. Subjective Symptoms. — Pain is always present, usually slight if the parts are quiet, but very intense during active or passive movements of the limb. If the fracture is near the head, the pain is more in the inguinal region; if at the base, it is more at the outer and upper part 440 INJURIES OF THE HIP. of the hip, and is increased by attempts at flexion or extension. The loss of function depends on the nature of the displacement. If unim- pacted, motion is lost, or at least the limb cannot be lifted in the recum- bent position if extended. If intracapsular, sometimes the patient can flex the thigh and knee and draw the heel up toward the thigh without fifting it. If the fracture is extracapsular, this is usually so painful that the patient prefers not to attempt it. If the fracture is impacted, the loss of motion may be slight, the patient may be able to lift the limb, to stand, upon it, or even to walk a few steps. The latter is particularly true of impacted extracap- sular fractures. Objective Symptoms. — On inspection the changed form of the hip due to the swelling is noticeable (Fig. 279) ; the inguinal fold is obliterated according to the site of the fracture. An angular deviation of the neck can be felt on deep pressure in Scarpa's triangle. The fold of the but- tock is less pronounced than on other side. Usually swelling is more marked in fracture at the base of the neck, corre- sponding to the greater loss of substance. If there is much extravasation of blood, ecchymosis appears sooner and more con- stantly in proportion to the proximity of the fracture to the shaft; if the fracture is extracapsular, it appears chiefly about the trochanter, but may extend over the entire thigh; if intracapsular, it appears in a few days in the groin below Poupart's ligament. Outward Rotation. — The lower extremity is normally rotated outward to a slight ex- tent on account of the forward direction of the neck. This is increased : in the absence of impaction by the weight of the limb ; with impaction, from the fact that it is chiefly the back part of the fracture surfaces which are impacted, the shaft being thus rotated outward. A line drawn through the axis of the lower extremity passes through the anterior-superior spine and the tip of the great toe; the part of the limb lying to the outer side of this axis is much heavier than the inner part. If the normal support of the limb, the neck, is broken, the thigh naturally rotates outward. The degree of rotation in impacted fracture depends upon the degree of impaction of the posterior fracture surfaces. In the absence of impaction the limb usually rests upon its outer surface, flexed slightly at the knee and hip with the heel touching the space between the internal malleolus and the tendo Achillis of the Fracture of the neck. FRACTURES OF THE UPPER END OF THE FEMUR. 441 other leg. The outward rotation is easily corrected. With impaction it is more difficult —in fact, it should not be attempted. Very rarely the linil) is rotated inward if the anterior wall of the neck is driven into the spongiosa of the trochanter so that the trochanteric fragment projects in front of the neck. The inward rotation is then overcome only by forcibly breaking up the impaction. Sometimes it may happen that the limb is rotated inward by the patient or bystanders, and can then naturally be rotated outward easily. Shortening. — Next to outward rotation, shortening is the most important symptom of fracture of the neck. It depends upon the lessening of the angle between the neck and shaft, which approaches more to a right angle, upon impaction of the fragments, or their displace- ment longitudinally. The shortening with impaction is rarely more than an inch. In intracapsular fractures the intact portion of the capsule prevents longitudinal displacement, or the lesser trochanter impinges against the upper fragment; the shortening is then moderate, not over Bryant's method of measurement. \\ inches. Later, if the capsule yields, the shortening may increase. (Bardeleben.) If the lower fragment rises above the neck, the short- ening may be from 3 to 4 inches. This does not take place gradually, but often suddenly if an impaction gives way and muscular action comes into play. Measurement is not always easy. Wight's method is the best; the anterior-superior spines should be horizontal, the limbs parallel to, or equally abducted from, the middle line of the body, and then the fol- lowing measurements made on both sides: 1, the distance from the anterior superior spine to the most prominent point on the internal malleolus; 2, to the most prominent point on the external malleolus; 3, the distance from the tip of the great trochanter to the most promi- nent point on the external malleolus; 4, the distance from the cleft of the knee-joint to the tip of the internal malleolus. Bryant's method consists in dropping a perpendicular from the anterior-superior spine and measuring the distance of the tip of the trochanter from this line, compared with the other side. (Fig. 2S0.) Very rarely there is an actual lengthening of the limb if the fragment of the neck is displaced upward. To this the term coxa valga is applied. (Thiem.) 442 INJURIES OF THE HIP. Muscular Relaxation. — Simultaneous with the shortening the muscles running from the pelvis to the thigh, especially the tensor fascia? latse and the gluteals, are relaxed. This produces a pathognomonic symp- tom: on the sound limb in the space between the trochanter and the crest of the ilium can be felt a resistance produced by the tension of the tensor fascia? lata? and gluteus medius; in fracture of the neck there is a deep depression here. (Allis, Bezzi.) In non-impacted fractures crepitus is occasionally obtainable on palpation; false motion is con- stant. Crepitus may be elicited by rotating the thigh or pressing on the back of the trochanter. If in doubt as to the existence of im- paction, one should never attempt to elicit crepitus by force, as impaction aids recovery. Crepitus is usually obtainable in unimpacted extracapsular fractures. False Motion. — False motion is usually demonstrable by rotating the thigh with the hand on the trochanter. The latter rotates about a shorter radius than on the sound side. In impacted fracture this is the natural result of the shortening of the neck; in unimpacted fracture the symptom is more pronounced the nearer the fracture to the trochanter. In pure extracapsular fracture the trochanter rotates about the long axis of the thigh; if there is impaction or splintering, the trochanter is widened. It is always displaced upward and backward in proportion to the amount of shortening and outward rotation. Marked upward displacement of the trochanter presupposes fracture of the lesser trochanter. If the extremity is rotated inward, these cases closely resemble iliac dislocation. In one instance Malgaigne discovered his error only on eliciting crepitus while attempting reduction. In impacted intracapsular fracture the trochanter is less prominent; also if both fragments are displaced upon each other. Diagnosis. — If all the above symptoms are marked, the diagnosis is not difficult, and one will easily be able to determine whether the fracture lies near the head or near the trochanter, whether free or impacted. The hip-joint may be greatly swollen, however, the shortening and outward rotation slight, and the functional loss partial. Even then the fracture can be determined with approximate certainty if the examina- tion is systematic and the symptoms taken up in order as mentioned. Usually it is not advisable to use an anaesthetic, as an impaction is easily loosened and the firm resistance of the impaction against every move- ment is the best aid in the diagnosis. For impaction speak further: slight shortening and outward rotation, intense pain at point of fracture, dis- tinct broadening of the trochanter, considerable swelling and ecchymosis around it, the ability to lift the extended limb, and the history, most of the fractures due to a blow upon the trochanter being impacted and extracapsular. Careful study of the symptoms, namely, the entire symptom-complex, will usually make it possible to determine the site of the fracture. The differential symptoms will be given later in tables comparing the diag- nostic points of injuries of the hip-joint and pelvis, with special reference to the exclusion of unilateral fractures of the pelvis, forward dislocation FRACTURES OF THE UPPER END OF THE FEMUR. 443 of the thigh, fracture with inward rotation, and iliac dislocation. The differential diagnosis from contusion of the hip-joint is often difficult; then' may be loss of function; elevation of the pelvis on the affected side may simulate shortening; the limb may be slightly Hexed and rotated outward. If the examination is hindered by severe pain, doubt may well be entertained unless Hodgson's suggestion is remembered: "If as the result of a fall upon the hip an elderly person is unable to use the affected limb, it is highly probable that there is a fracture of the neck, the more so if no especially great violence was applied in the fall such as would be necessary to produce a contusion of sufficient severity to render the thigh useless." Furthermore, in contusion all functional disturb- ance and suffering gradually decrease, whereas in fracture they increase. In fracture of the neck one should never fail to examine for simul- taneous fracture of the shaft. In incomplete fracture of the neck, the P^ig. 281. Fig. 282. Subcapital fracture with bony union. (Senn.) Complete absence of any union between the head and neck following subcapital fracture. (Senn.) limb is in its normal position or rotated outward slightly and somewhat shortened. It will be almost impossible to establish the diagnosis posi- tively. Usually the condition is regarded as a contusion of the hip-joint. It is self-understood that at the present time the x-ray gives the best information in regard to the injury present. Prognosis. — Fracture of the neck is by no means a harmless injury. It may lead — although rarely — to acute suppuration of the joint, which in view of the age of the patient is not to be underestimated. Sudden death may occur soon after the injury from fat-embolism, the marrow at the point of fracture being forced into the open lumen of an adjacent vessel. (Konig.) Protracted recumbency may increase old chronic affec- tions of the lungs, especially in the aged, with hypostatic pneumonia and death, or may produce bedsores resulting fatally. 444 INJURIES OF THE HIP. Fig. 283. In intracapsular fracture bony union is rare. Senn was only able to collect .54 authentic cases of this sort. With bony union the neck is found almost without exception to have disappeared entirely, the head being attached immediately to the trochanter. (Fig. 281. ) Very little callus is found on the surface of the neck. The larger proportion of the cases of bony union are incomplete fractures and those with impaction. Exact coaptation is indispensable for the union of unimpacted frac- tures. The majority of intracapsular fractures heal with pseudoarthrosis, the atrophied fracture surfaces being united by fibrous tissue of varying firmness. Sometimes the later use of the limb produces a sort of arthro- dial joint between the fragments. (Fig. 282.) Occasionally the head is entirely absorbed; the neck becomes smoothed off and forms a new articular surface. The strength of the neck is naturally diminished by the formation of a false joint so that the patients require the aid of crutches or a cane. Sometimes the lower fragment finds sufficient support against the hypertrophied outer arm of the Y-ligament and the tendon of the obturator externus to bear the weight of the body. Non-union in intracapsular fracture is referable to various circumstances. Often it is impossible to secure the immobiliza- tion of both fragments essential for the formation of callus on account of the inac- cessibility of the fracture. Further, the fractured head is subjected to conditions very unfavorable to its nutrition. Senile atrophy impairs the blood-supply of the neck; in addition the vessels are damaged by the fracture; those running through the ligainentum teres of the head are insig- nificant. The arteria nutritia colli entering the middle of the neck is "cut out" by a fracture near the head. The small vessels running into the neck from the inverted fold of the capsule are usually torn, and so the blood-supply of the head is entirely cut off. There is also an absence of any real periosteum at this point. These are certainly sufficient reasons for the lack of bone production. Probably the atrophy of the fracture surfaces and the disappearance of bony substance are due to the malnutrition of the tissues. In extracapsular fracture the conditions are quite different ; the fracture surfaces are usually held in apposition by impaction. Even if the fragments are displaced upon each other, the formation of callus is not often compromised — in fact, the callus may be so exuberant as to limit the movements of the hip-joint. The usual ring-shaped exostosis following impacted fracture is shown in Fig. 283. Complete union requires some time — two to six months. During this time, however, the Excessive callus formation following extracapsular fracture. 'Lossen.) X w < FRACTURES OF THE UPPER END OF THE FEMUR. 445 spongiosa is often completely restored, so thai the lamelhe conform fully to the demands made by tension and pressure. (J. Wolff.) The earning-effieiency of the patient is not restored, however, when union is complete. Some of the patients remain incapacitated on account of general atrophy and shortening of the limb; others on account of a pseudarthrosis or stiffness and sensitiveness of the hip or knee-joint; the majority on account of the high-grade shortening. Accordingto Haenel.of 19 cases only 2 recovered fully (= 12 per cent.); 13 were permanently injured ( = 77 per cent.); the average time of complete disability was eight months. Arthritis deformans does not develop so frequently after fracture of the neck as was formerly supposed, (v. Yolkmann, P. v. Brims. | Among a large number of hip-joints examined at autopsy by Arbuthnot Lane there were many cases of fracture of the neck; in three of these — one intra- and two extracapsular — a complete nearthrosis had formed close under the anterior superior spine between the ilium and an excessive growth of callus from the shaft of the femur. Treatment. — There are two important things to be effected in the treatment of fracture of the neck, the general care of the patient and union of the bones in proper position. Decubitus and hypostatic pneu- monia are to be prevented if possible. The patient should be laid upon a v. Volkmann-Hamilton suspension-frame, or a Messner adjustable bed, or upon a good horsehair mattress. Thin and weak patients should be supplied immediately with a water-cushion, and great cleanliness enforced, especially after defecation. The patient should not be kept horizontal during the entire period in bed, but be allowed to sit up partially as early as possible. Naturally the best treatment would be to do away with the recumbent position. This will be returned to later. Reduction will be required only for unimpacted fractures. The foot is grasped at the heel with one hand and on the dorsum with the other, and by gentle traction and inward rotation the limb restored to its normal position. If impaction is even suspected, it is not justifiable to attempt forcible reduction on account of the loss to the patient in loosen- ing an impaction. If there is impaction with slight shortening and outward rotation, the limb is simply laid between sand-bags and left alone. If there is marked displacement the surgeon has to consider: immobilization in Bonnet's woven-wire splint or upon a double inclined plane, or in a circular plaster splint enclosing the limb, hip, pelvis, and upper third of the sound thigh. These immobilization apparatus are usually only temporary; the plaster splint also only for transportation. For treatment in the recumbent position one should use v. Yolkmann 's adhesive plaster extension splint. v.Volkmann's Adhesive Plaster Extension Splixt. — Two strips of adhesive plaster [mole-skin plaster] 2h to 3 \ inches wide are applied on the sides of the extremity from the highest possible point on the thigh to about 4 inches above the malleoli, and bound on with a flannel roll. Below the ankle the strips diverge to a stirrup plate (spreader) about 1 inch below the sole of the foot. This plate prevents the strips from pressing against 446 INJURIES OF THE HIP. the malleoli and has attached to it the traction cord. The foot is ban- daged to a T-piece well padded and cut out at the heel. In a few hours, after the adhesive plaster has become adherent, the slide is placed under the foot and the weight attached. The weight should be heavy to be effectual; for well-developed patients 20 to 30 pounds, or even forty, and for weaker patients 10 to 20 pounds. If the traction is right, the pelvis is drawn down on the affected side so that the extended limb appears 1 to H inches longer than the other. Counterextension is made either by elevating the foot of the bed, by passing a rubber band around the other hip, or by placing a foot-piece against the other foot. By means of appropriately placed strips of adhesive plaster Bardenheuer always adds transverse and rotary traction; with v. Volkmann's T-piece the author thinks this is unnecessary. Fig. 284. Buck's extension with a v. Volkmann sliding rest. (Stimson.) By this method the average time of recovery is eight weeks. In v. Volkmann's experience the shortening is slight. The extension splint makes it possible for the patient to sit up in eight to fourteen days. According to Morisani, the shortening due to the diminution of the angle between the shaft and neck can be prevented by abduction. The Beely plaster suspension splint allows the patient to be shifted about more in bed. The splint extends from the groin to the base of the toes (Fig. 285), the rings being attached at the outer side of the middle line in front in order to maintain inward rotation. There are a number of other extension apparatus proposed: Bruns' modification of Dumreicher's sliding apparatus, and the apparatus of Hennequin, FRACTURES OF THE UPPER END <>F THE FEMUR. 447 Tillaux, and others, but they arc all more complicated than v.Yolkmann's or Beely's. In.. 285. Beely's plaster-of -Paris strip splint with suspension rings. The extension method as described above is especially suitable for extracapsular fracture. The traction is continued for three to four weeks, and then a plaster splint is applied and the patient allowed to go about Fig. 286. Hodgkin's suspended splint. (.Stimson.) on crutches. The method is hardly indicated for intracapsular fracture in the aged, as long experience has taught that bony union does not take place unless there is impaction. If there is impaction, bony union 448 INJURIES OF THE HIP. is good, and one may employ the ambulant treatment with advantage as described later under Fractures of the Shaft. With such a portable splint, accurately applied to prevent loosening of the impaction, the patient can be up and about in a short time. The author does not believe that it is advisable to torture old people for weeks with an extension or portable splint in the absence of any prospect of bony union. For such cases two methods can be used: ambulant treatment with massage, or excision of the fragment of the head. The former, recently recommended by French authors, aims to favor the production of a pseudarthrosis and prevent muscular atrophy. The muscles of the entire extremity are stroked and kneaded, especially about the hip; passive motion is begun as soon as the pain permits, later active motion, the patient being encouraged to move the limb and to walk as soon as possible. The treatment is indicated especially for weak, poorly nourished " catarrhal " patients. The results are fairly good. If dealing with fairly healthy individuals, immediate operation may be proposed. The fragment of the head may be excised, a simple opera- tion which has repeatedly given good results. Recently attempts have been made to preserve the head by screwing or nailing the fragment. Langenbeck fastened the fragments with screws or ivory pegs, an attempt made later by Konig and Trendelenburg. Schede has recently reported the good results of operation. Senn, in order to avoid operation, pro- posed to apply a splint made of plaster roll bandages while the patient stands upon a stool and the normal position of the limb is maintained by traction upon the foot. A pad is placed over the great trochanter to exert pressure in the direction of the neck and held by a screw arrange- ment; it is inspected daily and removed from time to time and the skin bathed with alcohol to prevent pressure-sores. The head has been removed recently with good results in old troublesome fractures of the neck with pseudarthrosis. (Fock, Konig, Hoffa.) In one instance Loretta freshened up the fragments with a raspatory nineteen months after the injury and obtained union in four weeks. Fracture of the Great Trochanter. — Separation of the great trochan- ter in the epiphyseal line or fracture later in life at the corresponding point, unaccompanied by fracture of the neck, is a very rare injury. Recently Morris was only able to collect authentic cases; in all of them the cause was direct violence upon the trochanter, usually a fall or blow. The amount of displacement varied according to the condition of the fibrous and tendinous covering of the trochanter, the fragments remaining in contact if the coverings were only partially torn. Symptoms. — The symptoms were those of severe contusion, fracture being suspected only from pain localized at the trochanter and increased by pressure. If the coverings and muscular attachments were torn from the femur, the fragment was always drawn upward and backward — even as much as 2\ inches — by the gluteus medius and minimus. In the absence of much swelling, flattening was noticeable at the site of the trochanter. Palpation of the fragments is often impossible on FRACTURES OF THE UPPER END OF THE FEMUR. 449 account of the tension of the surrounding soft parts or the swelling; on the other hand, crepitus may be elicited by flexing, abducting, and rotating the limb outward and pressing the fragments together. On account of the pain the limb is usually held slightly flexed and rotated inward. Motion is possible in all directions. Union is usually by the formation of a false joint. Bony union is only possible if the fragments are held together by the periosteum and fibrous covering. Treatment. — The treatment consists in immobilizing the limb in abduction, outward rotation, and slight flexion at the knee and hip. Fracture in the Epiphyseal Lines.— Traumatic Separation of the Epi- physis of the Head. — Traumatic separation of the epiphysis of the head has recently been made known by the works of Tubby, Whitmann, Sprengel, and especially by J. Poland, who cites 20 cases. The author has seen and operated upon 4 cases. Gerstle's statistics give 40 authentic cases up to the present time. Separation of the epiphysis may occur at birth from strong traction on the femur, but is most frequent between the tenth and fifteenth year, when the ossified head is more resistant than the epiphyseal line, so that direct violence affects the latter as the weakest part of the neck. Ossification is usually complete at the twenty-second year. The cause is commonly indirect violence, a blow upon the hip, or by falling upon the feet or jumping with excessive outward or inward rotation of the limb. The pathological findings vary; there may be a pure separation of the epiphysis, so that the head can be removed from the joint, or the line of fracture may extend through the epiphyseal line into the neck. Symptoms. — The picture is usually that of a subcapital fracture of the neck, the characteristic symptoms being soft cartilaginous crepitus, shortening even to 1 or lh inches, and generally marked outward rota- tion. Active motion is often unimpaired so that at the outset the patient may be able to walk. Diagnosis. — The diagnosis between fracture of the epiphysis and of the neck is often difficult, but is facilitated by the .v-ray. Without the latter the only positive evidence is to be obtained by operation. Prognosis. — The prognosis is favorable if appropriate treatment is begun at the outset, otherwise there are usually shortening and outward rotation. The femur is displaced upward on the head so that the angle between the neck and shaft is considerably diminished, giving the picture of a traumatic coxa vara. In all of the author's cases there was consid- erable limitation of motion. Pseudarthrosis also occurs. In one of the author's cases two years after the injury there was still no union between the head and neck, the head lying free in the cavity. If bony union occurs, the epiphyseal line is lost; later the growth of the femur is inhibited, slightly, however, as the growth in length is chiefly from the lower epiphysis. Treatment. — The treatment in recent cases is preferably the extension splint; in the absence of shortening, a well-fitting plaster splint. In cases of pseudarthrosis or malunion with deformity and great limita- tion of motion the author has obtained good results by excising the Vol. III.— 29 450 INJURIES OF THE HIP. head. In traumatic coxa vara with marked functional loss subtrochan- teric osteotomy is advisable. Separation of the Epiphysis at the Great Trochanter. — Poland col- lected 8 authentic cases of this kind; 3 were found on autopsy. The cause was always direct violence. The patients were all under seventeen years. Any marked upward displacement of the trochanter was usually prevented by the integrity of the numerous tendons and ligaments. Soft crepitus was occasionally elicited, especially by downward pressure. The condition of the soft parts determines the subsequent function. The latter may be very good; it also depends upon whether or not the trochanter follows the rotation of the thigh. If displaced upward, it may simulate a dislocated head. As the trochanter is covered with tissues poorly-supplied with blood and its nutrition is obtained from the shaft, suppuration takes place easily, especially if on a diagnosis of contusion the patient is allowed to go about during the first few days. GUNSHOT-WOUNDS OF THE HIP-JOINT. Gunshot-wounds of the hip-joint are not very common. In the statistics of the Franco-Prussian War (1870-71) there were only 128 cases. In the recent South African War Kuttner and Makins each saw only 1 case of small-calibre wound of the hip-joint. Most of the wounds were from before backward or in the reverse direction, v. Langenbeck assumes that a probable diagnosis of involvement of the hip-joint can be made if the opening is near the great trochanter and anterior- superior spine, namely, if the wound of entrance or exit is H inches below the anterior-superior spine. If the wound lies close in front of or behind the great trochanter, involvement of the neck is very prob- able. A bullet entering in front of the tuber ischii and emerging behind the great trochanter probably involves the head of the femur and portion of the acetabular margin. The damage to the joint varies from simple penetration of the capsule without injury of the joint-surfaces, fracture of the head, of the great or lesser trochanter, or a simple penetrating wound of the neck, to very extensive comminuted fracture of the entire upper end of the femur and the joint cavity. The bullet is occasionally found lodged in the head. Gunshot fractures of the femur and pelvis, especially of the horizontal ramus of the pubis, not infrequently involve the hip-joint through radiating fissures. If the bullet perforates the acetabulum, it enters the pelvis and may injure the viscera — for example, the bladder or rectum. Inversely' the bullet may enter the hip-joint through the abdomen or pelvis. Complications have been observed, such as wounds of the bladder and rectum with the discharge of urine or feces through the shot-wound, also wounds of the large vessels in the thigh and the large nerves, the crural and sciatic. A blind shot-track, namely, a wound of entrance but no wound of exit, is a frequent occurrence in shot-wounds of the hip. QUNSHOTtWOUNDS OF THE HIP JOINT. 45] Diagnosis. — The diagnosis of wounds of the hip-joint may be very difficult, particularly if the patient is able to be aboul for days or weeks after the injury. The x-ray makes it much easier at the presenl time, however. Usually the direction of the wound should guide the surgeon; further, the attitude of the patient at the time of injury, v. Langenbeck assumes involvement of the hip-joint if the wounds of entrance and exit lie within a triangle, the base-line of which cuts the greater trochanter with the apex at the anterior-superior spine. If the capsule alone is involved or the damage to the bone is slight, the symptoms in recent eases are often atypical. The first important symptoms an' the onset of inflammation, distention of the capsule, dis- charge of pus or sanies, and severe pain, in connection with the very im- portant symptom noted by v. Langenbeck, namely, a swelling which lifts up the vessels of the thigh. The traumatic inflammation usually begins in the second week after the injury, hut may be hastened by external circumstances, such as bad transportation or injudicious moving of the limb. If the inflammation appears very late, it may have been trans- mitted, assuming that the joint was uninjured primarily and that the bullet damaged only the periarticular soft parts. In the absence of a wound of exit the diagnosis is often possible if the symptoms of com- minution of the neck are present, namely, outward rotation, shortening, crepitus, etc. If the diagnosis is not positive, the injury should be treated as one of the joint. Probing or manipulation should be strictly avoided. Prognosis. — Thus far the prognosis of shot-wounds of the hip-joint has been very bad, the chief danger being that of infection, as its develop- ment is facilitated by the hidden position of the joint and the discharge of pus prevented by the thick covering of the soft parts. The prospect of recovery diminishes with the severity of the injury and the number of complications. Of the 128 shot-wounds of the hip in the Franco- Prussian War, the pre-antiseptic period, 102 died, mostly of pyaemia, the 4 cases amputated were fatal, and of the 27 resected 25 were fatal. Of the 97 non-operated and treated conservatively, 73 died. The 2 cases of Kiittner and Makins mentioned above, which were treated conservatively, recovered. Ankylosis is the almost uniform result of shot-wounds of the hip, usually with more or less shortening and anomalous position of the limb. The joint was often dislocated. The period of recovery averaged 6 months. Treatment. — Modern principles are opposed to any further attack upon the wound; the wounds of entrance and exit should be covered with an antiseptic dressing and the extremity immobilized as far as possible. Even in the field hospital with all the required aids at hand, conservative treatment is the rule and the extension splint of the greatest value. Resection of the upper end of the femur and tamponade of the joint are only indicated by severe suppuration. Amputation at the hip is indicated primarily or secondarily for very extensive laceration of the soft parts produced by heavy ordnance. CHAPTER XXIV. DISEASES OF THE HIP. INFLAMMATION OF THE HIP-JOINT (NOT INCLUDING TUBERCULOSIS) Pathological Anatomy. — Before describing the different clinical forms of inflammation of the hip-joint it is well to consider the pathological anatomy, many special features of which can be reconstructed by reason of their interrelationship. The primary synovial forms in which the cartilage is uninvolved, or involved only secondarily, are to be distin- guished from those forms following osteomyelitis or ostitis of the articular ends of the bones. Formerly all the varieties of coxitis to be considered here were included in the first group; to-day many are placed in the second — in fact, Konig and Brims are convinced that the large majority of all acute and subacute cases of coxitis in childhood and adolescence should be regarded as the result of osteomyelitis or ostitis of the articular ends. Primary synovitis, as in the other joints, may be serous, serofibrinous, hemorrhagic, or purulent. Coxitis — this applies to the serous and fibrinous as well as purulent inflammations — may be distinguished by predominance of fluid in the joint or of infiltration in the synovialis or in the periarticular tissue, or in both. The course varies neces- sarily with the form of inflammation. In the non-purulent type, if the exudation of fluid in the joint predominates, there will be an increasing distention of the capsule; if there is chiefly an infiltration of the syno- vialis or of the periarticular tissue, there will be adhesions between the contiguous synovial surfaces at an early period, or shrinkage of the capsule and the danger of stiffness. In the first case the danger is chiefly that of dislocation. Plastic infiltration of the joint-membrane represents a severer form of disease than exudation. Purulent coxitis behaves similarly. If accompanied chiefly by exuda- tion, one may hope to control the suppuration by timely drainage — in fact, in spite of profuse suppuration in the cavity, almost complete recovery without essential functional disturbance has been seen after early removal of the pus or even after spontaneous perforation. These are the cases of suppuration of the joint described by v. Volkmann as "catarrhal." At the onset the exudate is a thick, creamy pus mixed with yellow shreds; later it is a pure more or less slimy pus. It rarely results in shrinkage of the capsule or the consequent functional dis- turbances. Purulent infiltration of the synovial membrane is by far the most severe variety. A profuse exudation of fibrin in the tissues (452) INFLAMMA TION OF THE HIP- JOINT. 453 introduces the danger of plastic infiltration, the serious consequences of which for the joint have only recently been appreciated; this danger is increased by early destruction of the cartilage; the preservation of the entire limb is placed in question by a tendency to periarticular , abscesses. In primary ostitis one has to distinguish between an ostitis of the cartilage, usually causing separation of the epiphysis, and an osseous focal inflammation of the head and cavity. Ostitis of the cartilage varies in pathological significance; it includes the severe cases of suppuration ending in death or complete destruction of the parts — and those in which separation of the epiphysis occurs almost entirely without acute symptoms in the guise of a hydrops of the joint. In very severe cases the ostitis may extend beyond the trochanters and cause separation of their epiphyses. Usually the surgeon has to deal with the focal ostitis of the head and acetabulum described by Schede, Albert, and Muller, and which is similar to the focal form of tuber- culosis. The foci vary in size from that of a pea to that of a walnut, and are filled with granulations or peculiar white, chalky, thick paste or thick yellow pus. Usually they contain small or large sequestra distinguished by an intense yellow color. The infection of the joint takes place from these foci in the form of a purulent or cloudy serous synovitis. Traumatic Coxitis. — The mildest form of serous inflammation of the hip-joint is represented by the reaction of the synovial membrane to trauma which has torn the capsule without any essential damage to the joint. A sharp pain is felt at the moment of injury, but motion is not impaired. Later, motion is painful and limited. Gradually a slight swelling appears at the hip, hardly recognizable in well-built individuals, resulting from the partly serous, partly hemorrhagic, extravasation in and around the joint. Under appropriate treatment the symptoms subside in a relatively short time; infrequently a chronic hydrarthrosis develops with thickening and tenderness of the capsule. In intracapsular fracture there may be inflammation in and about the joint, occasionally followed by organization of the blood-clot in the joint and severe and permanent stiffness. Coxitis following Infectious Diseases. — A large percentage of the cases of primary synovial coxitis follow the numerous infectious dis- eases — scarlet fever, measles, diphtheria, pneumonia, typhoid, smallpox, gonorrhoea — and may be serofibrinous or purulent. They are produced by the specific germ of the infectious disease. Although the specific micro-organisms of only a certain number of the above infectious diseases are known, bacteriological examination has established the identity of the primary infection and the arthritis with reference to those which are known. Typhoid bacilli, Frankel's diplococcus, the meningococcus and gonococcus have been found repeatedly in pure cultures, in other instances mixed with staphylococcus and strepto- coccus, and usually mixed in cases of severe suppuration. The occasional negative results given in the literature cannot weaken the etiology; the difficulty of demonstrating the gonococcus, for example, 454 DISEASES OF THE HIP. and the destruction of the typhoid bacilli by overgrowth of the ordinary pyogenic forms, sufficiently explain the negative results. The specific germs of the infectious diseases are apparently able to produce only the serofibrinous and mild purulent cases of coxitis. The common pyogenic forms are almost always found, either alone or combined, in the strictly purulent processes, so that the addition of staphylococci or strepto- cocci may be regarded as essential to produce suppuration. We are naturally compelled to draw conclusions by analogy in regard to the etiology of inflammations of the hip-joint in infectious diseases the germ of which is unknown. It is impossible to specialize here with reference to the course <>\' coxitis in the various inf^Lious diseases. The author will confine himself to giving the cmnJI^^general and mentioning the peculiarities. In the majority of cases after temporary attacks of pain in various joints, occasionally with rise of temperature, there is an effusion in the hip-joint alone, or also in other joints, at the height of the disease or during convalescence. The effusion, usually serous or serofibrinous, generally subsides rapidly or persists and becomes chronic, finally with dislocation and hydrops. Less frequently there is inflammatory swelling of the capsule and soft parts about the joint, unaccompanied by any great amount of exudation but threatening the function of the joint. The purulent inflammations usually run the course of a "catarrhal" suppuration, but severe suppuration followed by destruction of the parts, ankylosis, or even death, does occur. The gonorrhceal and typhoid forms require special mention, the first on account of its ten- dency to produce ankylosis, the latter on account of the frequency of dislocation. Gonorrhceal coxitis is more frequent than was formerly supposed; it may be either in the form of a serous effusion or of a severe fibrinous inflammation with marked swelling of the tissues about the joint. In the latter case the tendency to ankylosis is greater than in any other disease, and goes hand in hand with extensive adhesions and a ten- dency to deformation. Under this head, according to Kdnig and Nasse, belongs the dreaded puerperal coxitis, occurring usually in the second week with severe pain and swelling of the extremities, followed by ankylosis. Actual suppuration is rare, but is then extremely severe and often fatal. The serous form may also end badly, either in spontaneous disloca- tion or recurrence and proliferation. According to Nasse, the chronic inflammations, either as a hydrarthrosis or with multiple villiform growths with or without effusion, are usually gonorrhceal. Fortunately the course is usually not so severe. In the majority of cases it is as follows: Accompanied by a moderate temporary rise of temperature, occasionally high at the onset, there are more or less diffuse darting and shooting pains in various joints. The arthritis (mon- arthritis or polyarthritis) follows; in a few days the pain diminishes, the temperature drops, the swelling subsides; in favorable cases return to normal in eight to fourteen days; in part of the cases recurrence and INFLAMMATION OF THE HIP-JOINT. 455 recovery after several years. Gonorrhoea! inflammation of the hip-joint occurs in young children, hut has a favorable course. Typhoid coxitis is characterized by an effusion distending the capsule, often without symptoms, and followed by unexpected spontaneous dis- location. Next to typhoid, scarlet fever and smallpox are most apt to produce spontaneous dislocation, hut to a lesser degree. The syphilitic affections which occur in the joints, not with least fre- quency in the hip-joint, as a simple inflammation without specific new formation, are to be classified among the inflammations of the joint following infectious diseases. The hip-joint may be affected alone or simultaneousMwith other joints. The exudative swellings of the joints at the hcgil^J^of the second stage of syphilis, often accompanied by fever and characterized by their painfullness, are well known. They may occur in children with congenital syphilis, often with violent symptoms simulating suppuration, so that operation has frequently been performed where specific treatment would have been proper. Primary purulent syphilitic coxitis is rare, and is seen more particularly in children with hereditary lues. With improper treatment it may merge into a chronic hydrops with swelling of the capsule. Acute articular rheumatism is a term still applied to the most diverse forms of infectious coxitis. It would be well to limit the term to those inflammations of the joint which react to salicylic acid. In the mild cases the surgeon is dealing with a serous inflammation, in the severe cases sometimes followed by shrinkage of the capsule, with a fibrinous inflammation. Following Konig's example, the author does not classify purulent coxitis with acute articular rheumatism merely because its clinical course is similar, and in those instances in which the etiology is lacking he prefers to admit openly the inadequacy of our present knowledge rather than attempt to conceal it behind a term which causes so much confusion as acute articular rheumatism. Sometimes a hidden focus of suppuration, sometimes a mild undetected diph- theria, is responsible for the involvement of the hip-joint. Coxitis in Infancy. — The etiology of the majority of cases of primary synovial coxitis of childhood, especially in early infancy, is almost unknown. Above the author has mentioned syphilitic and gonorrhceal coxitis, and must state here expressly that gonorrhoea and gonorrhceal coxitis are far more frequent in young children than is generally recog- nized. In young girls gonorrhceal vulvovaginitis sometimes occurs almost endemically as the result of infectious defloration, polluted cloth- ing, etc. In these cases the vulvovaginitis is the cause of the joint- disease. In the newborn it is an intrapartum infection. Nevertheless one frequently sees purulent synovitis of the hip-joint without recognizable cause (scarlet fever, measles, etc.) in which, above all, tuberculosis and syphilis can be excluded with certainty. The effusion in the joint develops with fever, pain, swelling, and usually redness of the surrounding soft parts, and is either incised or perforates spontaneously. The pus is very viscid, the synovial membrane deeply red and greatly swollen. The course is usually favorable, recovery gener- 456 DISEASES OF THE HIP. ally following with no or only slight impairment of motion. Dislocation may occur. Destruction of the joint is rare; even then the mobility is fairly good. The picture in general is therefore that of a catarrhal suppuration of the joint, except that the pain is a prominent symptom. Death has been observed only in the case of very weak children. These various forms of coxitis are most frequently seen during the first year, rarely after the fourth year. Krause found streptococci in the pus in 2 instances; in the majority of the cases accurate bacterio- logical examinations are lacking. Certainly paths of entrance for the micro-organisms are not wanting in earliest infancy, and in the occur- rence of septic infections in this period an important role has been recently ascribed to the Bacillus coli communis entering the circulation from the intestine. It is most probable that in these cases a primary osteomyelitis of the shaft of the femur is present. Coxitis by Direct Infection. — Primary synovial coxitis may be the result of direct infection from erysipelas advancing over the hip, from an adjacent phlegmon, or a penetrating wound of the joint. In the first two instances the surgeon is usually confronted with very severe sup- puration of the joint threatening the entire extremity or life; in the latter instance, namely, in penetrating wounds, the severity of the process depends upon the virulence of the bacteria in the wound. Symptoms. — In penetrating wounds the oozing synovia rapidly be- comes cloudy and purulent. The joint feels hot, is extremely tender, the least movement arousing vehement expression of pain; the con- stitutional symptoms depend upon the severity of the infection. In the worst cases there may be perforation of the capsule, abscesses about the joint, thrombosis of the adjacent vessels, and metastatic abscesses in the inner organs. Nowhere does the fate of the patient depend more upon early and energetic surgical treatment than in these suppurations of the hip-joint by immediate infection. Diagnosis. — The diagnosis of all the above-mentioned inflammations of the hip-joint as such is usually simple; the differential diagnosis between the etiologically contrasted forms is often difficult. It is not sufficient to diagnose a serous or a catarrhal inflammation of the joint, as the case may be; the surgeon should always try to find out the cause. The author need only mention the confounding of syphilitic affections in young children, accompanied by acute symptoms, with severe purulent processes, and the confounding of focal ostitis, giving the symptoms of chronic articular rheumatism, with the above. One should be particularly careful about the diagnosis "articular rheumatism," and not treat expectantly where immediate operation is required. A decision as to the severity of the inflammation is given by the intensity of the general and local symptoms, and in doubtful cases the character of the disease will be determined by aspiration. Treatment. — The treatment is on general surgical principles. Recent traumatic effusion demands appropriate immobilization of the joint, massage, and compression after disappearance of the first inflammatory symptoms. In immobilizing the lower extremity — this applies to all INFLAMMATION OF THE HIP-JOINT. 457 cases — the joint should be placed in the position giving the best function in case of stiffening, namely, slight flexion and abduction. If there is a hsemarthrosis and the blood is not rapidly absorbed, it should be removed by puncture to prevent organization and stiffness. Also to prevent stiffness immobilization should not be continued too long and passive motion begun early. In gonorrhoea] coxitis, if purely serous, aspiration and injection of a 3 per cent, carbolic-acid solution are beneficial. Recently Schuchardt used a 1 per cent, solution of protargol, in 1 instance with good result. By timely aspiration dislocation is prevented. If the swelling is chiefly Fig. 287. Pathological dislocation following scarlet fever. in the capsule, the injection may be made into the capsule in various places with a Pravaz syringe. For suppuration free incision is indicated, followed by irrigation, packing or drainage, or eventually resection. As to spontaneous dislocation of the hip, Degez has made a careful compilation of 81 dislocations following typhoid, rheumatism, scarlet fever, variola, gonorrhoea, influenza, and erysipelas. He showed that it was possible to effect reduction some time afterward, the manipulation being the same as for traumatic dislocation, namely, traction, counter- traction, and direct pressure. The accompanying illustration (Fig. 2S7) is of a dislocation following scarlet fever which was reduced with com- 458 DISEASES OF THE HIP. plete success, as can be seen, four months later. Operation is indicated if repeated attempts at reduction are unsuccessful. Coxitis from Acute Osteomyelitis. — Recently P. v. Brans and Honsell published an excellent work from the Tubingen clinic on acute osteo- myelitis of the hip-joint, v. Volkmann, Schede, Stahl, W. Miiller, Albert, and Kblisko haying: previously studied the disease and its secjuelfe. The following description is taken from the data of v. Brans and Honsell. In the last forty years 106 cases of osteomyelitis of the hip were seen in the Tubingen clinic, in contrast to 500 of the lower end of the femur. Only 3 of these were attributed to a cold; 15 were referred to trauma, such as a blow, fall upon the hip, slipping, etc. At the onset of the disease 12 patients were from one to five years old, 25 from fiye to ten, 43 from ten to fifteen, 23 from fifteen to twenty, 2 from twenty to twenty-five, and only 1 twenty-six years old. Males were represented somewhat more frequently; there was no difference in the frequency of the disease on the two sides; in 4s cases the process was on the right, in 40 the left, in 12 bilateral. Pathological Anatomy. — The disease may start in the femur or acetabulum. Inflammation of the epiphysis alone is very rare. (W. Miiller, Jordan, Lannelongue. More often the upper end of the shaft alone is affected, or the neck with or without the trochanter, but usually the shaft and epiphysis are involved simultaneously; in addition the shaft of the femur may be involved partially or entirely. It is best to designate the disease of the entire upper part of the femur to the leyel of the lesser trochanter as epiphyseal in the broader sense, as indicated by Jordan, Miiller, Schede, Stahl, v. Brims, and Honsell. In osteomyelitis of the epiphysis, in contrast to disease of the shaft, the individual foci remain circumscribed for a long time. The foci develop into confluent or multiple cavities filled with pus or granulations and sequestra, the latter usually small and derived from the spongiosa, rarely from the cortex. The sequestra may be gradually absorbed or remain for years. There is rarely any extensive formation of new bone about the foci, but rather atrophy and absorption of the bone involved. In the upper end of the femur there is occasionally a more diffuse purulent infiltration of the spongiosa. as first described by v. Volkmann and Leveque, and recently confirmed by v. Brtmsand Honsell. Usually, however, there are discrete foci of infiltration and suppuration scattered through the head, neck, and trochanter. These cavities do not generally contain any sequestra. Sometimes there is extensive necrosis; for example, in a case of v. Brims and Honsell the entire upper end of the femur from the intertrochanteric line was transformed into a sequestrum only loosely connected with the shaft. The inflammation may come to a standstill within the bone without perforation, but usually advances. If the foci are near the surface, perforation into the joint or into the tissues about the joint follows the destruction of the cartilage or periosteum; there is then a more or less extensive irregular loss of substance on the surface of the neck, head, INFLAMMATION OF THE HIP- JOINT. 459 and trochanters. If the defects are numerous, the appearance may be that of a tuberculous coxitis, particularly if covered with flabby yellow granulations. (W. Muller.) If the foci lie deeper in the bone, they may perforate directly outward or through superficial cavities and occasion considerable loss of function, even complete destruction of the head and neck. The foci close to the epiphyseal line are especially important. To a certain degree the cartilage forms a natural barrier against extension of the inflammation, and is therefore rarely perforated over a large area. Consequently the inflammation more often advances along the epiphyseal line, loosening the epiphysis and finally separating it from the shaft. The epiphysis may be completely necrotic and the head be found as a free body in the joint. The epiphysis may become adherent again, partly to the femur, partly to the acetabulum. The epiphyses of the trochanters may be loosened and separated in the same way, or the neck may be separated partly or entirely beyond the epiphyseal line. If the disease involves the acetabulum primarily or secondarily, there may be either small defects, soft discolored spots in the cartilage, or large portions of the cartilage may be destroyed and the underlying bone appear rough, eroded, and filled with granulations; finally there may be deep loss of substance, necrosis, and perforation of the wall and margin of the cavity. In primary osteomyelitis of the acetabulum, as described recently by Bardenheuer and Obalinsky, in the early stages there are circumscribed foci, with or without sequestra, and mostly close to the Y-cartilage, later, destruction of the cartilage, perforation of the acetabulum, and extensive destruction of the ilium or even of the more distant parts of the pelvis. Occasionally in osteomyelitis of the pelvic bones a periostitic abscess may perforate indirectly into the hip-joint. (Fleury, Schede, and Lannelongue.) Inflammation of the synovialis of the hip-joint accompanies the disease of the bone, varying from a mild adhesive serous or catarrhal inflammation to suppuration and sanious ulceration of the joint. Per- foration of a large bony focus or a periarticular abscess into the joint may cause severe suppuration and destruction of the cartilage, liga- mentum teres, and capsule. The milder forms of inflammation are usually seen in connection with small osseous foci which have existed for some time and lead to the formation of adhesions between the contiguous synovial surfaces of the joint before perforating. So far only the acute stage of the first weeks and months of osteomy- elitis have been discussed. If recovery' occurs eventually, changes are always found in the bone which greatly affect the future usefulness of the limb. Exceptionally thickening of the upper end of the femur is found, especially the trochanteric portion, and even less frequently of the intra-articular portion. (Jordan, Albert, W. Muller, v. Brims, and Honsell.) There may be focal or diffuse sclerosis of the affected area or marked atrophy of the upper end of the femur. The deformity depends upon the amount of destruction, the condition of the epiphyseal cartilage, and 460 DISEASES OF THE HIP. the tension and pressure in the affected parts. There may be a char- acteristic depression of the head at the epiphyseal line, often with broadening of the head, the mushroom form. (Albert and Kolisko, W. Miiller, v. Bruns, and Honsell.) Or the head may be smaller than normal, the head and neck being more cylindrical, oval, or conical. The neck is more frequently deformed than the head. It may be so shortened that the head is attached to the trochanter. It is very fre- quently bent, as described first by v.Volkinann, later by Schede and Stahl, Diesterweg, and W. Miiller. According to v. Bruns and Honsell, three types of curvature may be distinguished: the entire upper end of the femur, including the trochanters, is bent downward and inward; the neck is bent downward at the base; the neck is bent at the head toward the tip of the lesser trochanter. The shaft of the femur may also be curved. In contrast to the upper end of the femur, the acetabulum reacts with a most prolific production of new bone. The wall of the acetabulum becomes thickened, bridges of bone spring from one side of the cavity to the other or to the femur; the entire cavity may be rilled and large osteophytes form around it. "Wandering" of the cavity, which is observed so frequently in tuberculous coxitis, is not rare. The permanent changes in the joint are proportional to the duration and intensity of the inflammation. If the inflammation is slight, the resorption of the exudate may be followed by adhesions between the capsule and surface of the cartilages resulting in severe loss of motion. If the destruction in the joint was greater, extensive adhesions form between the articular surfaces, the capsule and periarticular soft parts are transformed into thick, dense fibrous tissue, the joint becomes ankylosed. That a separated epiphysis may become adherent to the acetabulum has already been mentioned. The deformities of the pelvis as a whole are almost identical with those in tuberculous coxitis. Symptoms. — The onset is usually sudden. People previously perfectly well, usually children or young adults the picture of health, are suddenly taken sick, with high fever, often with chills and mental disturb- ances. Intense pain is complained of in the affected limb, localized in the hip or, as in tuberculous coxitis, in the knee. It is greatly increased by pressure upon the trochanter or the sole of the foot, as well as by the slightest movements of the limb, so that the use of the limb is impossible and the patient is obliged to remain in bed from the first day. A diffuse swelling, cedematous and boggy, soon appears at the hip, especially in the gluteal region, over which the veins are dilated. It is usually not confined to the hip, but extends over the entire thigh to the knee or even farther downward. If the pelvic bones are involved, swelling may appear within the pelvis at the anterior-superior spine or extend to the symphysis. Exceptionally the pain is slight ; there is a gradually increasing limp, the severe symptoms appearing after weeks or months. As emphasized by W. Miiller, v. Bruns, and Honsell, epiphyseal osteomyelitis may occa- sionally begin as a polyarthritis, namely, with swelling in several joints, as in acute articular rheumatism, the joints being affected simultaneously INFLAMMATION OF THE HIP- JOINT. 461 or consecutively. The process then involves other epiphyses beside that of the hip. The inflammation subsides spontaneously in most of the joints, while at the same time severe inflammation develops in one of them. Course. — The later course varies according as the exudation perforates the capsule and appears al the surface or not. \on-perforation is not infrequent. In the IOC) cases in the Tubingen clinic there were 20 of this sort, 3 were bilateral. The severe constitutional disturbances in these cases lasted from three to six weeks, and were followed slowly but steadily by improvement; the pain ceased, then the fever; the swelling subsided, and recovery followed in from four to six months. The only results of the disease are then the changes in the bone and the functional disturbance. If perforation occurs, the course is more severe. The acute general symptoms subside usually in from one to three months, possibly partly in connection with perforation of the capsule. Otherwise the course of the disease is determined essentially by the duration and intensity of the discharge. Before the pus perforates the skin it usually burrows among the gluteals and adductors and infiltrates the soft parts extensively, the average time before perforation occurs being six months. The suppuration is maintained not only by the joint, but also by foci in the bone with or without sequestra. The discharge is extremely protracted, and many patients succumb to it who have survived the acute stage; it usually lasts about three years. Occasionally the disease is very acute; the picture is then that of a severe fulminating sepsis, and death follows in from five to twelve days after the onset, usually after an affection of the lungs has been added. As mentioned, in the cases of non-perforation recovery follows within a year; in the cases with discharge usually in from three to four years if the patients do not succumb meanwhile. Complete restitution occurs only in the mildest cases; usually a certain amount of disability persists corresponding to the changes in the bones and joint; it is particularly in such instances, especially if the continuity of the bone and the joint is preserved, that contractures develop, the majority of which are a combination of flexion, adduction, and inward rotation, or flexion, abduction, and outward rotation. Numerous other combinations also occur. Where the disease is bilateral the contractures may be symmetrical or not, or there may be stiffness in one joint and dislocation in the other. In severe bilateral adduction contractures the limbs may be crossed. Firm ankylosis follows the contracture sooner or later in the majority of cases. Shortening is usually less conspicuous and is evidenced by a high position of the trochanter; the cause is either atrophy of the upper end of the femur, flexion of the neck, or widening of the upper margin of the cavity. Spontaneous dislocation is very frequent, in almost a third of the cases, and is due either to distention of the capsule in the cases of serous or catarrhal coxitis or to destruction in the purulent cases. The displacement is almost always backward and upward, and usually occurs late in the disease and upon slight provocation. The 462 DISEASES OF THE HIP. usefulness of the dislocated limb is generally very much impaired, as mobility is usually slight. Dislocation forward is very rare; it has been seen as the obturator and iliopubic variety, (v. Brims and Honsell.) Separation of the epiphysis, as mentioned, is very frequent. The symptoms vary greatly; the limb is rotated outward or inward, and more often flexed than extended. The femur may be displaced upward and backward on the epiphyseal fragment and the trochanter lie 1 \ to 2\ or even 4 inches higher than normal. Albert and Blasius have reported cases in which the femur was displaced forward on the hori- zontal ramus of the pubis. The mobility of the limb varies; naturally when the separation takes place it is abnormal, later there is more or less firm ankylosis. Sometimes the trochanter can be pushed up and down for a long while afterward; if such cases are seen at a late period, they may be mistaken for congenital dislocation of the hip. As stated, the fracture may not lie in the epiphyseal line, but in the neck; the diagnosis then depends upon the .r-ray. Recurrence may take place years after recovery. Of the 106 cases in the Tubingen clinic, 15 died; in 4 of these resection or exarticulation was performed. Diagnosis. — Tuberculous coxitis, the most important consideration in the diagnosis, is excluded by the acuteness of the onset. The diagnosis is more difficult if the disease is subacute or is seen at a later period; the appearance of the disease in perfectly healthy adolescents, sponta- neous dislocation, separation of the epiphysis, or coexistent osteomyelitis in other parts of the body, would then be important. Further, a bac- teriological examination is of value, as in all cases of osteomyelitis the pvogenic cocci are present, chiefly Staphylococcus pyogenes aureus, rarely streptococcus or pneumococcus. The rr-ray, particularly in older cases, gives the diagnosis with certainty. According to Bardenheuer and Obalinsky, in osteomyelitis of the epiphysis and acetabulum thickening can be felt per rectum at the acetabulum. Prognosis. — According to v. Brims and Honsell, the prognosis can be summarized as follows: At the onset the condition of the patient is almost always extremely serious. A decision during the acute stage as to the further course cannot be given; in the experience of some observers it would appear that death is more frequent than recovery. Later, after the severe symptoms have subsided, the prognosis is essentially better and depends chiefly upon whether the coxitis is serous or catarrhal (without perforation) or puru- lent (with perforation of the capsule and skin). In the former instance the prognosis as to life is favorable; in the latter death may follow sooner or later in the event of general sepsis or pyaemia, or from the exhaustion due to protracted profuse suppuration and amyloid degeneration of the viscera. A fatal termination is more likely if there is separation of • the epiphysis or osteomyelitic foci elsewhere, especially if they involve the bones of the pelvis. The permanent changes left in the hip by the disease are very severe, although the view exists that in time the patients are able to work even in the event of separation of the epiphysis or dislocation. Recurrence is occasionally observed, as in osteomyelitis TUBERCULOSIS OF THE HIP-JOINT. .ji;;; in general, but so rarely that it docs not earn- any weight in the prog- nosis. Treatment. -Although recovery has occasionally followed simple arthrotomy, the author would recommend resection of the hip-joint as the only effectual operation in acute suppuration of the joint, for only resection is able to obviate the immediate as well as the remote dangers of suppuration. In the Tubingen clinic resection was performed in 14 cases; only 2 patients died at the close of the operation, the rest recovered and were discharged in from two to three months. The resulting defor- mities are treated according to the rules to be described later under treat- ment of deformities of the hip in general. TUBERCULOSIS OF THE HIP-JOINT (COXITIS TUBERCULOSA). Tuberculosis of the hip-joint — coxitis tuberculosa — may occur at any time of life, but is chiefly seen in children between the second and eigh- teenth year, and more particularly from the fifth to the tenth year. Before the second or after the eighteenth year the affection is very rare, although Crocq, Brodie, and Lannelongue report coxitis in the first year, and Morel-Lavalle, and later Marjolin and Leon Labbe, demonstrated tuberculous inflammation of the hip in the foetus and newborn. These are isolated observations. The disease may attack otherwise healthy persons, but is more frequently found associated with tuberculosis elsewhere. According to Schmalfuss, the hip-joint is affected in 12 per cent, of all tuberculous lesions. It stands third in frequency in tubercu- losis of the bones and joints. For the general statistics we are indebted to Watson Cheyne. From his compilation of the statistics of Billroth, Menzel, Jaffe, and Schmalfuss, and 602 personal cases, the vertebrae were found to be affected in 23 per cent., the knee-joint in 16 per cent., and the hip-joint in 15 per cent, of the cases. This predisposition of the hip-joint is referable to the burden of supporting the body-weight and the contingent exposure to irritation and injury. Little can be said especially further in regard to the etiology that does not apply in general to tuberculosis elsewhere. Predisposition, heredity, the injurious influences of poor nourishment, bad air, weakening illnesses, etc., play an important part. If tuberculosis exists elsewhere, namely, in the lungs, bronchial glands, etc., this focus is to be regarded as the primary source of the hip disease. In rare cases the iliac bursa, which often communicates with the hip-joint, may transmit the tuber- culosis from some other part. Often the inflammation is preceded by slight trauma, so that the latter should be considered as a predisposing cause. In many cases the author obtained a specific history in the parents. Pathological Anatomy. — It is very important to determine the origin of the tuberculous process. Numerous investigations have shown that the disease may start in the femur, the acetabulum, or the synovial membrane. The femur and acetabulum are involved primarily with 464 DISEASES OF THE HIP. about equal frequency (Haberen, Konig, Marsch, Lannelongue, Menard, Oilier), the synovialis much less frequently (16 to 17 per cent, v. Volk- mann, Riedel). Primary Tuberculosis of the Synovial Membrane. — In this variety the inflammation of the joint is primary, the caries of the joint secondary. The author believes with Konig that it begins with a sero- fibrinous exudation followed by tuberculous degeneration and the forma- tion of spongy tuberculous granulations filling the cavity. The fibrin plays an important part in the further advance of the disease; as Konig expresses it, the fibrin gradually eats away the cartilage. The places on which the fibrin is deposited depend upon the attitude and movements of the thigh. The result of inflammation of the synovialis varies: there may be only typical tuberculous granulations, or also suppuration and caseation in the joint. The pus destroys the surface of the cartilage more than the fibrin does. The bone is thus exposed and subjected to a process of destruction dependent essentially upon mechanical factors, as will be seen later. The pus may work its way through the bone or soft parts and perforate outward. Fig. 288. Fig. 289. Severe tuberculous coxitis. Capsule greatly distended by pus. Resection. At a, in the middle of the head, the granulations have perforated the cartilage. In the neck, close to the epiphyseal cartilage, lies a free caseous se- questrum the size of a cherry pit. The abscess cavity perforated into and infected the joint through the fistula 6. (Krause.) Resected upper end of femur from a girl five years old. Natural size. Large wedge-shaped subchondral focus in the head, with demarcation well advanced. Cartilage lifted off like a bulla. (Krause.) Primary Tuberculosis of the Bone. — The focus may be either in the head, neck, trochanter, or acetabulum. Of 381 cases operated upon by Konig, the focus in 146 cases was in the head, in 187 in the acetabulum, in 28 in the neck, in 5 in the trochanter, in 5 in the shaft, in 10 in the pelvis above the femur. In the femur the primary focus is most fre- quently in the epiphysis of the head, the part of greatest growth and therefore with the fullest blood-supply. According to Konig, the foci in the hip are as frequently single as multiple. The infection is usually transmitted through the blood to the bone and spreads thence in all directions. The inflammatory changes in the bone at the outset are not rri:i:i;f the limb corresponds to the duration of the disease and the consequent disuse of the entire limb. The blood- vessels about the joint occasionally undergo secondary changes. Lan- nelongue called attention to the not infrequent diminution in size of the femoral artery and its main branches, and other authors have made these changes responsible for the trophic disturbance in the limb by reason of the decreased blood-supply. In very marasmic and cachectic patients there are occasionally obliteration of the femoral vein and phlegmasia dolens. Lannelongue also called attention to the secondary changes in the lymphatics and glands. The inguinal glands are almost always inflamed and swollen. Occasionally the lymphatics are found involved up to the spinal column. Involvement of both hips simulta- I-'ig. 297 Pelvic changes in coxitis. (Hofmeister.) neously or consecutively is very rare; infection of the second hip usually follows weeks or months after the first. Menard saw 7 cases in one year. The author has also seen several. Symptoms. — The symptoms may be divided into those of three periods, the prodromal stage and first and second stage of florescence, although this division does not apply to every case, as one or the other of these stages may be less distinct. The first symptoms at the onset are usually pain and the so-called voluntary limp. Pain may be the only symptom present for some time and a neuralgia of the joint be suspected. It may occur either spon- taneously or after walking or other exertion. At night the child may awake with a sudden cry, complain of pain in the joint, and then fall 472 DISEASES OF THE HIP. asleep. If such an attack is watched, it is seen that the cry of pain is because of a sudden muscular spasm. The pain is increased by any manipulation forcing the head into the cavity, namely, pressure upon the trochanter, upon the knee, the sole of the foot, or in Scarpa's triangle. Occasionally pain is elicited by pressure per rectum against the pelvis opposite the acetabulum. The pain may radiate to the knee, especially on the inner side, and simulate an affection of the knee — in fact, it has often been provocation for considering resection of the knee-joint. If children complain of pain in the knee, one should always examine the hip-joint, as the referred pain is due to direct irritation of the nerves of the hip-joint. The intensity of the pain varies; at the onset it may be so severe that any jarring or change of position causes great discomfort and confines the patient to bed; then again it may not appear until later when the focus perforates into the joint. The voluntary limp is often the first noticeable symptom of the disease. The patient drags the limb mechanically without being conscious that he is protecting the joint. It may be constant or inter- mittent; the latter is especially common at the onset. Sometimes the limp is more marked in the morning than in the evening, sometimes the reverse. With these two symptoms, pain and the limp, only one other is necessary to make the diagnosis positive; the most gentle attempts to abduct or rotate the limb passively produce a distinct reflex contraction of the hip muscles. The author regards this as a very important symptom. It is obtainable even though the child is able to walk. The muscular contraction gradually produces fixation of the hip in an abnormal typical position. This marks the beginning of the second stage. If pain, the limp, and reflex muscular contraction are present, the inguinal glands are usually swollen. The second stage is the period of development of the contracture, which latter may take place in two ways; the limb first becomes flexed, abducted, and rotated outward, and later flexed, adducted, and rotated inward, or it may assume the second position at the outset. The first position gives an apparent lengthening. (Fig. 298.) Bonnet refers this lengthening to the distention of the joint by effusion and granulations, the typical attitude of the limb giving the greatest space in the joint and so diminishing the pain. Konig conceives rightly that the position is due to the effort of the patient to guard the limb against the pain produced by movements of the joint. In walking, the weight of the body is therefore thrown as much as possible on the other limb; consequently the latter is adducted. The affected limb becomes abducted involuntarily, as it were. In walking the hip is flexed slightly and rotated outward to obtain the most comfortable position. The patient often walks on his toes to protect the hip. The effect of flexing, abducting, and rotating the hip outward can be best illustrated on one's self. The false attitude of the limb is therefore assumed voluntarily by the patient, although unconsciously; it can be completely overcome under anaesthesia. After a longer period, however, the muscles shrink and fix the limb in a pathological position which cannot be overcome under TUBERCULOSIS OF THE HIP-JOINT. 473 an;esthesia. This abnormal position, which may last for months or years, is naturally not without influence upon the carriage of the pelvis and the spine, the changes in the pelvis being the most important. In the erect position with the limb abducted and flexed, to approximate the foot to the ground the pelvis must be inclined on the affected side, the inclination being proportional to the amount of abduction and Fig. 298. Fig. 299. . Coxitis in the stage of flexion, abduction, and outward rotation. Coxitis in the stage of flexion, adduction, and inward rotation. flexion. This produces an apparent lengthening of the limb, the sound limb being adducted toward, and the affected limb abducted away from, the middle line of the body. In the erect position the distance from the anterior-superior spine to the internal malleolus will thus be shorter on the sound than on the affected side. This leaves out of consideration the cases in which destruction of the head or acetabulum has produced dislocation and consequent variation in the length of the limb, such as 474 DISEASES OF THE HIP. may occur at an early period. If the patient goes about on crutches or is recumbent, there is no cause given for abducting the limb, so that it is only flexed and rotated outward. If compelled to be recumbent, the patient lies upon the sound hip, with the affected limb supported in flexion upon it, the position giving the greatest comfort and protection against movement. The limb is adducted and rotated inward. If this position is maintained, the muscles become shortened, especially the adductors. This attitude of flexion, adduction, and inward rotation usually takes place at a later period in the disease, namely, in the so-called third stage, in contrast to the position of flexion, abduction, and outward rotation of the second stage. (Fig. 299.) The cause of these gradual changes, beginning usually with marked flexion, has been a complete mystery to surgeons for a long while, as is still shown by many surgical articles. The explanation, however, is very simple, and is the same as given above: the recumbent position is rendered more and more necessary by the severe pain, the patient always lying upon the sound side. As the disease progresses the contracture in flexion, adduction, and inward rotation develops from the abduction attitude on purely mechanical grounds. Occasionally, however, the primary abduction persists, the joint having become so fixed that any change of position is impossible. In walking, in order to prevent painful movements of the hip-joint, the pelvis is lifted on the affected side to compensate the adduction of the thigh, so that there is an apparent shortening. Corresponding to the obliquity of the pelvis there is a compensatory static scoliosis and curvature of the linea alba. In the recumbent position the flexion is easily concealed by a compensating lordosis. The fold of the buttock is higher upon the affected side. In addition to the characteristic symptoms, pain, limp, and con- tracture, the inguinal glands may be swollen and tender, or may even suppurate and perforate. The hip is sometimes greatly enlarged like a "white swelling," more marked if the muscles are atrophied; the entire hip appears densely infiltrated, the contour of the great trochanter is obliterated, the inguinal fold lost. Palpation meets with firm resist- ance; pressure is painful. In other cases the swelling may be equally extensive and fluctuating if an abscess has formed, or there may be mul- tiple abscesses at various points on the hip and thigh. The usual site is at the inner border of the tensor fascia 3 latne. They may be round or elongated, lobulated or hour-glass shape, especially those forming beneath Poupart's ligament with through-fluctuation between the abscesses above and below the ligament. The temperature is rarely an indication of the extent of the process or of suppuration, as is well known, in contrast to almost all the other infectious diseases. It does give information, however, in regard to complications, namely, the involvement of other organs. Fever may be absent, or of an indefinite remitting character for some time, or continuous, varying between 100.4° and 102.2° F. A sudden rise of tem- perature accompanied by severe pain in the hip-joint indicates sudden perforation of an osseous focus into the joint with reasonable certainty. TUBERCULOSIS OF THE HIP- JOIST. 475 Dislocation, most frequently backward, is not an uncommon occur- rence in the later stage when the process is well advanced. It is not unusual for the cases to be seen for the first time at this stage, after the abscess has perforated and sinuses are present. The shortened limb is flexed, adducted, and rotated inward; the trochanter lies above Roser- Xelaton's line; the remaining portion of the head can he felt upon the ilium. The normal shape of the head is rarely preserved unless the dislocation has occurred early following trauma. Iliac dislocation usually occurs if the limb is adducted; the pubic and obturator types are extremely rare. (Oilier.) If the cavity has "wandered " upward and backward, the trochanter above Roser-Nelaton's line projects sharply sideways; the head cannot be displaced upward. Occasionally the "wandering" takes place directly upward; the head is then checked by the anterior-superior spine, the symptoms being similar to those of supracotyloid dislocation, namely, shortening, outward rotation, and displacement outward of the femur; crepitus is usually present on motion. If a pathological dislocation or "wandering" of the cavity exists, walking is usually facilitated by the development of a compen- satory genu valgum attitude of the knee. Diagnosis. — At the onset the diagnosis may be difficult, and yet is of the greatest importance at this stage for a favorable prognosis and successful treatment. A limp existing for some time and evidence of a unilateral affection of the hip-joint are very suspicious of tuberculosis if associated with pain in the hip, either spontaneous or elicited by pressure against the trochanter, in Scarpa's triangle, or against the acetabulum per rectum. If the pain is referred to the knee and the hip is apparently free, careful abduction of the thigh in the recumbent position and demonstration of the adductor reflex are positive for coxitis. In walking, the patient usually favors the affected limb. If told to stand erect, the weight is thrown on the sound limb and the affected limb flexed, the patient often standing upon the toes to prevent pressure upon the hip. The history, appearance of the patient, pallor of the cheeks, the anorexia, the disinclination to play, the restless sleep and "starting pains," and the frequent demand of younger patients to be carried contrary to their usual habit, all point to coxitis. On the other hand, a child with coxitis is frequently well nourished and feels and looks well. This is a very important point to be borne in mind, as the first mild symptoms are easily disregarded in view of the good general condition. The existence of abscesses or fistulas facilitates the diagnosis. Abscesses in the pelvis are often palpable only by relaxing the abdom- inal muscles and exerting gradual pressure in the iliac fossa, carefully pushing the intestines aside. Digital examination per rectum in a small pelvis may demonstrate the presence of an abscess or roughness of the bone opposite the acetabulum. To demonstrate a contracture, the patient is placed in the dorsal position upon a firm, flat surface, the anterior-superior spines marked with ink, and the examination made on both sides. A compensatory lordosis (Fig. 300) is recognizable by lifting the thigh until the patient's 476 DISEASES OF THE HIP. back is flat upon the table. (Fig. 301.) The degree of flexion can then be determined. In very young children in whom the spine is very flexible there is often inflexion of the spine instead of a curvature, so that the arch is absent. Abnormal rotation, inward or outward, is easily recognized by comparing the patellae or the feet. The shortening or lengthening and abduction or adduction are deter- mined by comparing the position of the feet with reference to the anterior- Fig. 300. Flexion of the hip, lordosis of the lumbar vertebra?. superior spines; as has been seen, great differences in length can be compensated by elevation or depression of the pelvis. With the line joining the anterior-superior spines at a right angle to the long axis of the body: if the limbs are of equal length, there is no abduction or adduction; if the flexed limb is longer, there is an actual lengthening as in dislocation downward; if it is shorter, there is an actual shortening dependent either upon arrested development, separation of the epiphysis, Fig. 301. The degree of flexion is shown when the lumbar spine is held in contact with the table by flexing the other thigh. (Whitman.) dislocation, or "wandering" of the cavity; in all those conditions the relation of the trochanter to Roser-Nelaton's line is important. If the limbs are of equal length and the anterior-superior spine on the affected side is lower than on the other, there is an actual shortening If the flexed limb is longer, there is an apparent lengthening due to abduc- tion (Fig. 302) ; if the limb is shorter, there is an actual shortening. If the TUBERCULOSIS OF THE HIP-JOINT. 477 anterior-superior spine on the affected side is higher than on the other, there is an actual lengthening if the Limbs appear of equal length, an apparent shortening or abduction of the Hexed limb if the limb is shorter; and finally there is an actual lengthening if the flexed limb is longer. The degree of abduction or adduction is best estimated by abducting Fig. 302. Fig. 303. Apparent lengthening. When the Apparent lengthening. Fixed abduction at 45 degrees, distorted limb is brought to the me- When the anterior-superior spines are on the same plane. dian line the pelvis is so tilted that as in the illustration, the deformity is evident. (See the abducted leg seems longer. (See Fig. 302.) (Whitman.) Fig. 303. ) (Whitman.) (Fig. 303) or adducting (Fig. 304) the limb until the spines are in the same level, namely, until the line joining them is at a right angle to the long axis of the body. Slight differences may be due to superficial destruction of the joint-surfaces or slight "wandering" of the cavity. The trochanter projects laterally more particularly with 'wandering" of the cavity or dislocation. 47; DISEASES OF THE HIP. The au-ray should be used if the slightest doubt exists as to the nature of the disturbance in the hip. As mentioned, tuberculous foci even of considerable size may exist for a long time without symptoms; by the .r-ray the size and position of the focus can often be determined and the proper treatment instituted. The earlier this is done the better the prognosis. In many cases the destruction in the joint can be demonstrated clearly. I _ r . 305.) To obtain accurate infor- mation, it is necessary to .r-ray both hips ; in children the cartilages and the cleft of the joint are recognizable in the sound hip as a transparent semicircular zone. On the affected side the line of the joint is either darkened or blurred (Fig. 306), or the extent of the destruction is recogniz- able by irregular opacities or more or less distinct villiform projections. Konig has emphasized properly that small foci in the bone, either on the pelvis or in the head, neck, or tro- chanter, and slight abnormalities show- too indistinctly in the .r-ray, on account of the delicate structure of the bone or the relative thickness of the soft parts, to give reliable information for the diagnosis and prognosis. It is well known that the a>iay pictures of the hip-joint are generally less dis- tinct than those of most of the other , joints. Konig calls attention to the Apparent shortening ine adduction ot tnp J © right thigh is made evident by the invoiun- fact that large and small granulating tary eroding of the legs when the anterior- fogj are eas il v overlooked Or mistaken superior spines are on the same point. e , ,* P . . , (Whitm f° r abnormal formations in the me- dulla. The value of the x-ray picture is unquestionable if the surgeon is dealing with extensive destruction, marked changes in the head, "wandering" of the cavity, periosteal pro- liferation, separation of the epiphysis, or spontaneous dislocation. In a few instances the author distinctly saw the separated head lying in the cavity and the shaft of the femur displaced markedly upward; in others the head had disappeared completely, only a slight thickening being recognizable on the shortened neck. Atrophy of the femur is also shown clearly, the bone being smaller and more pervious. In one case, following resection, the upper end of the shaft was the thickness of a lead-pencil, although the function was good. Even as ankylosis often TCHERCULOSIS OF the hip-joist. 479 shows clearly, so the surgeon can frequently study the arrested develop- ment of the pelvis, which, as mentioned, may be pronounced in cases of contracture of the hip-joint acquired in early life. How careful one should be in interpreting the above symptoms is shown by the fact that the limp and attitude of the limb in adduction and flexion have often been regarded as indicating coxitis, whereas in reality quite another lesion existed. Menard recently reported a case Fig. 305. Early stage of disease of the left hip-joint (to the right in the picture) of the synovial type, showing irregularity in the shape of the acetabulum. (Whitman.; sent to the hospital with the diagnosis of coxitis in which, after being under observation for three months, appendicitis was established. Differential Diagnosis. — Although the symptoms at first glance are obviously characteristic of coxitis, one should never omit to examine the entire body carefully. A number of diseases which must be excluded give a similar picture, namely, growth-pains, arthritis deformans, fracture of the neck, traumatic separation of the epiphysis, congenital 480 DISEASES OF THE HIP. dislocation, traumatic dislocation, arrested development (especially after infantile paralysis), coxa vara, hysteria, neuralgia, monarticular rheu- matism, acute and chronic synovitis, tumors of the bursa?, spondylitis, echinococcus, gonorrhoea, syphilis and other infectious diseases, osteo- myelitis, malignant neoplasms. Pains due to growth may cause a slight limp in one limb, are usually located in the shaft, but may resemble joint-pains and be accompanied Fig. 306. Advanced disease, showing wandering of acetabulum and the obliquity of the pelvis due to adduction. Actual shortening one inch, apparent shortening three inches. (Whitman.) by slight elevations of temperature. They soon disappear with rest in bed and are rarely elicited by forced movements. Arthritis deformans may produce changes in the joint giving several symptoms common to tuberculous coxitis, but it is extremely rare in child- hood and then follows trauma. The thickening in the joint is so pro- nounced that confusion is hardly possible. The course is more regular and more chronic, although there may be slight exacerbations. Eleva- tions of temperature always speak for tuberculous coxitis. TUBERCULOSIS OF THE HIP JOINT. 481 Fracture is excluded by the history, the patient beingabout n|> to the time of injury without pain in the hip, the violence being sufficient to explain a fracture or separation of the epiphysis. On the other hand if before the trauma, which is held responsible for the affection of the hip, the patient had complained of trouble in the hip in proportion to which the injury was slight, and tuberculosis is found in the other organs, or there is a tuberculous heredity, and the pains in the hip appear several weeks after the injury, then there is every reason to suspect tuberculous coxitis. Congenital dislocation may be thought of if the coxitis has produced a dislocation, but in the congenital form there is no pain during passive motion in contrast to the fixation due to the reflex muscular contraction in coxitis. In numerous instances, however, a careful review of the history has been necessary to establish as to whether or not the limp existed previously with pain and contractures and abscesses. Paralytic dislocation takes place naturally after the paralysis. Traumatic dislo- cation is the direct result of great violence, so that there is no reason to think of coxitis unless the hip was previously affected. A limp may be due to shortening in one of the bones of the limb; the bone affected is determined by accurate measurement. If it is the femur, the examination also gives evidence as to pain, mobility, and crepitus in the joint, and whether the cause of the shortening is in the joint or in the shaft. Coxa vara and downward inflexion of the neck are to be thought of if the shortening is in the articular portion of the femur, and if, in addition to the shortening, which may be even 3 inches, the limb is adducted and rotated outward. The extended position is common, although flexion is often reported. Adduction can usually be carried out easily and without pain; abduction and inw T ard rotation are limited. The differential diagnosis may be very difficult, however, if the inflexion of the neck is due to an inflammation of the hip-joint without suppura- tion, and then requires the support of a careful history, regard for the general condition, and the .r-ray. Neuralgic pains in the hip-joint are often difficult to distinguish from those of coxitis, especially if the prodromal stage is protracted. Brodie, Stromeyer, and Esmarch have called special attention to hysterical joint; it occurs usually but not exclusively in females. The hip may be flexed and rotated inward, there may be variations of temperature, but it is usually possible to find a cause for the hysteria (pelvic trouble or other nervous disturbances) or verify the free mobility of the joint by diverting and fixing the attention of the patient or examining under anaesthesia. The .r-ray is also conclusive. The pain usually wanders. The result of the treatment employed on the supposition of a joint- neuralgia (massage, outdoor exercise, ice-bag, compresses) clears up the diagnosis. Rheumatism, monarticular, in the hip-joint is usually preceded by repeated attacks, is accompanied by friction-sounds in the joint at an early period, rarely causes so much stiffness as tuberculosis, and is more Vol. Ill— 31* 482 DISEASES OF THE HIP. painful under unfavorable atmospheric conditions. It is improved by the exhibition of salicylic acid. With polyarticular rheumatism confusion is hardly possible Chronic synovitis is always without swelling of the synovialis. Evi- dence of tuberculous foci in other parts of the body would aid the diagnosis of coxitis in doubtful cases. Acute synovitis may give the same symptoms as acute tuberculosis of the joint, for example, after sudden perforation of an osseous focus. Trauma often immediately precedes both conditions, and the synovialis is usually much swollen. In the absence of a history of previous limping, weakness, etc., puncture may be necessary in doubtful cases. Tumors of the bursa:* of the hip, especially inflammation of the iliac bursa, may produce the same anomalous position of the thigh, namely, abduction, outward rotation, and flexion, as coxitis. Abscesses of the bursa? may present at any point on the hip or thigh and wander as in tuberculosis. Pain radiating to the knee is common to both affections. In bursitis abduction, outward rotation, and flexion may be effected without pain, whereas movements in the opposite direction can only be carried out under anaesthesia on account of the firm reflex muscular contraction. The iliac bursa occasionally communicates with the hip- joint so that inflammation of the former may be transmitted to the latter. Abscesses anywhere in the pelvis easily perforate into the bursa and from there into the joint. Spondylitis is always to be thought of in connection with such abscesses. The author can only recommend urgently that the spinal column be examined carefully in every ease in which coxitis is not clear; abscesses from either direction may appear at any point in the pelvis or on the thigh; in spondylitis a reflex spasm of the iliopsoas may produce an anomalous position of the thigh as in coxitis. A superficial examina- tion may therefore have serious consequences. Under anaesthesia the mobility of the hip can be ascertained and the conditions verified by the x-ray. Echinococcus will be diagnosed from the history and aspiration. Gonorrhoea! inflammation of the hip is not uncommon, and often produces complete bony ankylosis, in dired contrast to coxitis, in which bony adhesions between the articular surfaces is extremely rare. Evi- dence elsewhere of gonorrhoea confirms the diagnosis. Syphilis may also produce bony ankylosis, and will be determined by the history, evidence of a primary lesion, and the effect of specific treatment. Special attention is called to the extremely severe pain of syphilitic coxitis. One of the author's female patients cried out night and day on account of the pain. She was not a nervous woman, but the least contact of the bedclothing caused intense agony. The diag- nosis of the joint-affections following the infectious diseases, such as measles, scarlet fever, typhoid, variola, puerperal fever, will depend upon the history. These are usually severe suppurations, not infre- quently causing spontaneous dislocation and ankylosis. Osteomyelitis, especially of the epiphysis, under circumstances can TUBERCULOSIS OF THE HIP-JOINT. 483 be very difficult to distinguish from tuberculous coxitis, as they both give the same symptoms except that the process in osteomyelitis is usually more rapid. High temperature and simultaneous involvement of several bones speak for osteomyelitis. If fistulas exist, the microscopical exam- ination of the scrapings may give information, although mixed infection very frequently makes the differentiation difficult, as noted by P. v. Bruns. Malignant tumors— sarcoma and carcinoma — may give the symptoms of coxitis. They are more common in advanced life, whereas tubercu- losis is seen chiefly in youth. A primary neoplasm in the hip-joint is especially confusing; on the other hand, if there is a carcinoma of the breast or sarcoma of the maxilla, or malignant neoplasms elsewhere, one naturally thinks of secondary involvement. Periosteal sarcoma of the trochanter usually forms a larger tumor than the swelling of coxitis, but may give fluctuation if softening occurs. The overlying skin is usually more brownish and the veins more dilated than in tuberculosis, and the inguinal gland more swollen. In sarcoma the tumor spreads. Myelogenous sarcoma occasionally produces the same pathological posi- tion of the limb as coxitis; Englisch reports several cases in which the limb was first abducted, then adducted; in others there were dislocation and fracture of the destroyed part of the joint. If the neoplasm is very large, it may give pulsation, vascular murmurs, and parchment crack- ling- In either carcinoma or sarcoma exploratory incision is indicated if all other evidence is exhausted. Carcinoma of the neck of the femur is not very rare, the swelling about the joint being insignificant, while the inguinal glands are greatly enlarged and the interior of the bone is gradually absorbed. Motion in the joint is usually possible for a long time actively and passively until the destruction has advanced so far that fracture or dislocation occurs, usually from slight trauma. Prognosis. — The serious character of a tuberculous arthritis should always be kept clearly in mind. Even in apparently mild cases one should be careful not to give a favorable prognosis unconditionally as encapsulated foci may be the starting-point of new inflammation even after years. Nevertheless a tuberculous inflammation of the hip-joint gives a better prospect of recovery and of being limited to' the focus than tuberculosis of the viscera. The general condition of the patient is significant. In cachectic children with extensive tuberculosis the prognosis of coxitis is obvious; likewise with an inherited tendency it is always possible that the tuberculosis may develop in other places and death result from general tuberculosis or involvement of the lungs or meninges. P. v. Brims found that in spite of local recovery, 6 per cent, of the patients died of phthisis in the first decade, 9 per cent, in the second decade, and 7 per cent, in the twentieth to the fortieth year. Severe sup- puration always jeopardizes life, especially on account of the amyloid degeneration of the viscera, the kidneys being most frequently involved. A high-grade albuminuria usually means amyloid degeneration of the kidneys. In the author's experience the average duration of life in the 484 DISEASES OF THE HIP. non-suppurative cases is three and one-half years, in those with suppu- ration about five years. The largest number of recoveries occurs up to the fifth year, the number decreasing slightly to the twentieth year and then rapidly. Recovery after the fortieth year is almost impossible, especially if there is suppuration, v. Brims gives 50 per cent, of recovery in general. Cold abscesses perforating on the hip or thigh may favorably influence the course by giving drainage to the pus. Sequestra in the bones of the joint may occasion long-continued suppuration, exhaustion, and cachexia. Cases of spontaneous absorption of the abscess are reported, especially in youth. Recovery frequently follows the injection of iodo- form-glycerin. Perforation into any of the pelvic organs can always be serious. Putrefaction of the pus prevents the formation of a limiting wall of cicatricial tissue and the fixation of the joint. In the non- suppurative form, even after considerable destruction of the joint, cicatricial tissue may solidify the joint; bony ankylosis is very rare. Destruction of the bone is always followed by more or less functional disturbance. If the head is absorbed, its function may be assumed partially by the neck; if the destruction is more extensive and involves the epiphyseal cartilage, there may be dislocation, wandering of the cavity, separation of the epiphysis, arrested development of the femur or of the entire limb. Reduction of a dislocation is followed immediately by luxation unless the destruction of the femur or pelvis is slight, and except in the case of sudden dislocation at the beginning of the disease, in which by careful treatment the prognosis is favorable. Conservative treatment to-day holds out greater hope of preserving the joint and bringing about a recovery even in severe cases, whereas formerly operation was almost always resorted to and all diseased and destroyed tissue removed, naturally with greater functional loss. The author's experience at least attests to the good results of conservative treatment; the earlier the rational procedure is instituted the more favorable the outcome. At a later stage operation may be the only means of saving life. The prognosis is favorable in direct relation to the youth of the patient; in children the disease is more apt to be limited than in older people. Diminution of the pain and the limp and greater mobility of the joint are the favorable signs of convalescence. The pathological fixation in flexion, rotation, abduction, or adduction can usually be corrected, and merely the shortening left to be compen- sated mechanically. The adaptability of the body to the deformity is astonishing; even marked contractures are often compensated by eleva- tion or depression of the pelvis, lordosis, or scoliosis. The shortening is the chief source of the functional disturbance. In the author's experience, and according to the various statistics, recovery without shortening belongs to the greatest rarities. Of 106 cases cited by v. Brims and ^\ T agner, only 4 recovered without shortening, and these were without suppuration. Actual shortening is due partly to arrested development of the thigh, partly to upward displacement of the tro- chanter above Roser-Nelaton's line, the latter being the cause in 80 TUBERCULOSIS OF THE HIP JOINT. 485 per cent. The average shortening up to the fifth year without sup- puration is 1, ! inches, with suppuration 2\ inches; in coxitis developing in later life, 1 ', to 2 inches. According to v. Bruns, death occurs in 40 per cent, of the cases after an average duration of three years, and chiefly from tuberculosis of the lungs and meninges, and general miliary tuberculosis, meningitis being the cause in nearly a third of the children up to the fifteenth year. Recovery occurs in 77 per cent, of the cases without suppuration, in 42 per cent, with suppuration, suppuration more than doubling the mortality. Recovery in the first decade is represented by 65 per cent., in the second decade by 56 per cent., in the third and fourth by 28 per cent., and in the fifth by (i per cent. After the twentieth year recovery is rare, especially in the fungous purulent type. Billroth saw 11 instances of complete recovery, and IS with functional impairment of the joint, in 54 cases. Among 63 cases Jacobsen saw 17 recoveries and 40 deaths. Of 27 patients ranging from one to fifteen years, seen by Ilenle in the Breslau clinic, 20 were treated successfully. Of Marsch's 139 cases, 48 died, 54 recovered, 9 remained unhealed, and 22 were lost sight of. Of Konig's 410 cases, seen during a period of twenty years and followed after being discharged, 168 died, 248 recovered, 140 of the latter being treated conservatively, 114 by opera- tion. Treatment. — In the first stage three things are essential: general diet, prophylaxis, and the local treatment. As in any tuberculous arthritis, rest is of first importance, more so in the lower extremity than in the upper. Its value is attested by the mildness of the inflammation in the second joint in the cases of bilateral coxitis which are kept in bed. Fresh air is also of great benefit, although one should not sacrifice the resting of the limb to obtain it. Experience has taught that well-to-do patients, not obliged to live in small rooms in a narrow street, make a much better recovery than the poor. Sea air is especially beneficial; it is there- fore a great help to such poor patients if they can enjoy the sea air for a time in the summer outing of some Children's Aid Society or other charity organization. Mountain air is also good. Also treatment in a well-conducted salt-water bath. The diet should consist of nutritious, easily digested food. Inunction with green soap, as first recommended by Kapesser and Kollman, has always proved serviceable in the author's experience; in the abdominal position the back and both limbs are anointed two or three times a week with a good soft soap (sapo kalinus Du Yernoy [Stuttgart]), as in mercurial inunction, and removed in one-half hour with a sponge. The treatment should be continued for several months. The result is often surprising; swollen glands diminish, the appetite and general strength increase, even old fistulas may close rapidly. Embro- cations of tincture of iodine or mercurial soap have been proposed, also application of an ice-bag or Priessnitz compress (cold, wet com- press). Albert's thermopuncture, formerly approved and recommended, is little used at present. 486 DISEASES OF THE HIP. Local Treatment. — Aside from the general treatment and the use of drugs, the local treatment is the most important factor in the entire management of tuberculous coxitis. The advantages of extension are numerous: Recovery is more rapid, the pain is diminished, and fixation in a pathological position is prevented. Fixation in slight abduction and flexion is the least troublesome, gives the patient the least discomfort in sitting, and most effectually compensates any shortening. The favor- able influence of extension upon the recovery is due to the affected articu- lar surfaces being held apart; there is thereby less tendency to suppu- ration, and the compression thus made by the capsule and ligaments being put on the stretch aids the resorption of the joint-contents. The swelling often decreases visibly. That the joint-surfaces are drawn apart by extension is shown in frozen specimens made on the cadaver; a separation of If inches has been seen. (Konig, Bradford.) The reciprocal irritation of the joint-surfaces being stopped, the painful mus- cular spasms, which so frequently disturb the child during sleep, cease. The spastic contraction of the muscles gradually relaxes to normal. In children the weight to be effective should be from 25 to 30 pounds; in adults 40 pounds or more, being increased until the pain ceases. Even children sometimes notice the comfort produced by the extension and beg for more. If there is no anomalous position, extension prevents it; if present, it corrects it. In the absence of any anomalous position an adhesive- plaster extension splint is applied, as described under fracture of the neck, or a laced legging (Gamasche) upon which traction can be made. Counterextension is maintained by elevating the buttocks or by an elastic perineal band attached at the head of the bed and weighted. If the limb is abducted — that is, apparently lengthened — the extension should overcome and not increase the deformity, as even by simple extension the pelvis is drawn down on the affected side and the limb thus abducted. This should be prevented by appropriate counterextension; it may be advisable to apply extension to the other limb. Adduction is overcome by simple extension or counterextension on the sound side. Portable Apparatus. — A very important part of the action of extension is the fixation of the diseased joint, yet unfortunately this fixation is not complete, independent of the amount of weight applied. The portable apparatus more nearly fulfils the requirements of immobilization essential to recovery, and has the additional advantage of allowing the patient to be about and in the open air. Among the apparatus used at the present time, disregarding the obsolete forms, should be mentioned the American long traction hip splint, not only because the ambulant treatment of coxitis was first inaugurated by the efforts of American colleagues and has found its widest application in America, but also because the description of this splint best defines the requirements of a rational apparatus. This splint, first introduced by Davis, Sayre, and Bauer, has many modifications at the present time; Fig. 307 shows those of Taylor and Shaffer. The splint is held firmly by a pelvic brace, miERCULOSIS OF THE HIP-JOINT. 487 extension being made by means of adhesive-plaster strips applied to the leg and attached to a foot-pieee which can be screwed up or flown. These American splints appear to the author to fulfil only partially the above requirements; they overcome the reflex spasm of the muscle favorably, but, on the other hand, do not give complete fixation as shown by Lovett's experiments. At each step there is alternating pressure and traction — " push-and-pull action" — upon the joint. Nevertheless Fig. 307. Long traction hip splints. (After Taylor and Shaffer.) the numerous statistics of Shaffer and Lovett show that the great majority of cases are cured by the favorable action of the splint, although the final result is compromised very often by the limb becoming fixed in a false position, by deformities of the knee-joint, or the development of a pes equinus. The undesirable results produced by the splints constructed according to Taylor's principles are referable to the incomplete fixation of the hip-joint. 488 DISEASES OF THE HIP. These drawbacks can be avoided if the limb can be extended con- tinuously in the proper position and the hip-joint immobilized and exempted from the pressure of the body-weight. Successful attempts have been made in this direction. The apparatus of Wallace Blanchard, Stillmann, Phelps, Lovett, and Dane Fig. 308. were the first to be constructed to this end. Phelps added traction in the direc- tion of the neck. Lovett combined the Thomas splint with a foot-piece after the principle of Taylor. Dane's new splint, similar to the one of P. v. Brims Fig. 30; >. Hessing's apparatus for coxitis. Celluloid sheath apparatus. (After Lorenz.) widely used in Germany, and to be described later under fracture of the shaft, is said to be very serviceable. In contrast to the American splints should be mentioned the German splints, especially those of v. Bruns, v. Volkmann, and Liermann. Hess- ing's is the best of the German apparatus; it is almost perfect in its miEUcl-LOSls OF THE II1I' JOINT. 489 action, and therefore cannot be recommended too highly. The author uses it almost exclusively in his better practice It consists of a sheath splint modelled to the limb and attached to a well-fitting pelvic brace. The latter consists of two detachable halves accurately shaped to the pelvis. '1 "he joint between the pelvic brace and the sheath can be adjusted and locked. On the side of the apparatus the author has added a firm iron strip to hold the limb abducted at any angle desir- able, and in front a reinforcing strip of iron curved from the side-piece to the front part of the pelvic brace. (Fig. 308. ) With this apparatus the hip-joint can be immobilized absolutely, the other joints remaining free. Fig. 310. Fig. 311. Fig. 312. Lorenz' plaster-of-Paris splint. If the pain in the joint has entirely ceased and the surgeon can assume that recovery is complete, slight mobility in the joint may be allowed by loosening the screws. The apparatus is w T orn for two or three years, being so made that it can be lengthened with the growth of the child. Unfortunately its construction requires skilful workmanship. Fortunately for poor patients, the surgeon is able to give them the benefit of the ambulant treatment with less expensive apparatus. Heusner constructed a simple apparatus of iron strips padded with felt. Lorenz makes the sheaths out of celluloid instead of leather. (Fig. 309.) Port makes a plaster cast of the pelvis and limb, and on it shapes a sheath apparatus out of strips of cellulose and sheet-iron with a stirrup 490 DISEASES OF THE HIP. to which rubber bands are attached to exert traction. The perineal pad is covered with a rubber tube filled with fluid, preferably glycerin. Instead of plaster or cellulose, other materials may be used: wood, glue, silicate, felt, etc. [Cellulose is a kind of wood fibre.] A well-fitting plaster splint may be used if portable apparatus are not available. Surgeons are indebted particularly to Lorenz for the technie, which is followed here: all that is necessary are plaster-of-Paris roll- bandages and an iron brace, which any mechanic can make. A plaster splint is applied smoothly from the lower part of the thorax to the middle of the thigh. After it has dried thoroughly in one or two days, the iron brace (Fig. 310) is bound on firmly with muslin bandages. Fig. 313. Fig. 314. Billroth'* plaster-of-Paris splint. Traction is by means of an elastic band; the splint is cheap and durable (Fig. 311), and can be made removable and readjustable (Fig. 312). The plaster splint without the brace is also very serviceable if it includes the foot and extends to the lower border of the ribs, fitting accurately about the pelvis to insure uniform pressure. In all severe cases it is better to include the other thigh also and unite both thighs by a transverse piece. This gives very good fixation and allows the child to go about with a walking chair. (Figs. 313 and 314.) In applying such extensive plaster splints it is an advantage to use special extension and immobilization appliances like those suggested by Scheinpflug, TUBERCULOSIS OF T1IE HIP-JOIST. 491 v. Bruris, and others. The author uses Sehede's tal)le, with exeellent results. The patient lies with his shoulders upon the table, the perineum is supported against a padded upright, and the limb is held extended either by means of a screw appliance or by an assistant, and the plaster bandages applied. Wieting recommends suspending the patient in order to apply the splint in the position in which it will be used. He employs a sort of felt bathing-tights, in which the patient is suspended by a rope and pulley attached to a Beely-frame or a ring in the door-jam. The head is also slightly suspended. The plaster splint is put on over the felt tights after adhesive-plaster strips have been applied to the limb and weighted. A walking brace is incorporated in the splint up to the thigh, extending about an inch below the sole of the foot. In about two days the sound foot is raised on a thick sole and the patient allowed to go about. A removable splint may be made of cellulose or celluloid instead of plaster. All splints are worn until the joint is not sensitive to the body-weight or to a blow upon the head of the trochanter. The splint is then replaced by a removable sheath splint, leaving the knee free. Proper mechanical treatment certainly has a favorable effect upon the mortality. Recently the author has followed all the cases treated for years with sheath splint apparatus, and has found that recovery with a movable joint is possible if the patients are taken in hand early. This is usually not the case, however, and a certain amount of stiffness is generally the result. There is always shortening of from \ to \\ inches if the process is well advanced at the beginning of treatment. If the orthopedic measures are consistent and exact, the later position of the limb is relatively good compared with previous results. In most of the cases the author has been able to obtain the desired position, namely, slight flexion and abduction. One no longer sees the severe flexion and adduction contractures formerly observed. Abscesses are less frequent with the above treatment than with the extension treatment alone, and their course is decidedly influenced by exact fixation, extension, and disencumbrance of the joint. Abscesses or fistulas are not a counterindication to the ambulant method, as a fenestrum can be cut in the splint and the abscess aspirated and iodoform glycerin injected. The 10 per cent, emulsion in glycerin (v. Brims' iodoform oil) is the best. As the mixture is not easily absorbed, its local action lasts longer. Many attempts have been made to influence the process by injecting iodoform directly into the joint, using from 4 to 30 c.c. at intervals of from eight to fourteen days according to the age and reactivity of the patient. Krause inserts a long needle above the trochanter perpen- dicular to the axis of the thigh and in the frontal plane, the patient being in the dorsal position with the limb extended, adducted, and rotated slightly inward; the needle slides over the head into the joint to the floor of the cavity, v. Biingner locates the femoral artery as it crosses the horizontal ramus of the pubis and inserts the needle in the sagittal direc- tion at the inner border of the sartorius in a line drawn from the tip 492 DISEASES OF THE HIP, of the great trochanter to the artery at the point mentioned. Rise of temperature, weakness, and pain may follow the injection, but usually disappear on the second day. Schuller uses a 15 per cent, emulsion of iodoform in glycerin or water with 0.5 to 1 per cent, guaiacol, or 5 per cent, mucilage of gum arabic and 1 per cent, of carbolic acid. Instead of glycerin, gelatin or oil (v. Bruns) may be used. Landerer recommends highly an injection every other day of a 1 to 5 per cent, aqueous solution of sodium cinnamate into the diseased tissue, and in adults :>7.) The cartilage of the head is usually intact, exceptionally destroyed in spots. Polished and hardened surfaces point with certainty to arthritis deformans. Occasionally the hone has been found slightly compressible; in other instances abnormally hard. The femur, recently studied by Sndeek and Bahr in a large number of cases, shows a visible ami palpable ridge at the point where the curvature takes place in the neck. It is supposed to he an increased deposit of hone augmenting tin Fig. 336. Fig. 337. Coxa vara. (Specimens of Hoffa's.) strength of the tension lamelhe. If this augmentation is absolutely or relatively insufficient, a curvature backward and downward is supposed to take place. This ridge is unquestionably present, but its significance is disputed by Bahr, who regards it rather as a point of attachment for the strong fibres of the capsule. Great uncertainty exists at the present time as to the actual condition of the bone in coxa vara. Muller, Hofmeister, Lauenstein, and many others assume a localized late rhachitis. Kocher assumes a special form of juvenile osteomalacia. No evidence is given for the view of a late rhachitis, the conclusion being drawn by analogy from Mikulicz' theory of the origin of genu valgum in adolescence. Kirmisson and Charpentier believe that there is usually an arthritis deformans, and apparently deny 516 DISEASES OF THE HIP. the existence of a particular coxa vara adolescentium. Kiister assumes an ostitis fibrosa. Whitman conceives that there is merely an excessive increase in the normal process, as the inclination angle is always dimin- ished toward the end of childhood. The author thinks that in coxa vara adolescentium the affection is not a uniform one, but that a number of different processes may produce the deformity in connection with the same injurious external influences. As to these external causes, there is no question as to the action of the body-weight — that is, we are dealing with a static deformity. Kocher, Manz, and Bahr believe that if the bone is abnormally pliant the neck may be bent if the legs are habitually held spread apart and rotated strongly outward. As this attitude is one frequently assumed by those engaged in agricultural work, especially dairymen, Kocher calls coxa vara an occupational disease of adolescence. The increased material observed recently proves, however, that the disease occurs in various occupations in which the injurious attitude is not always demon- strable. It is certain that in a relatively large number of cases a faulty disposition of the weight is the cause, as, for example, in the genu valgum of bakers and typesetters and the flat-foot of waiters. Stieda cites the frequency of a lymphatic, chlorotic diathesis in the patients concerned. Diagnosis. — The diagnosis is usually easy if the history and local condition are compared carefully; nevertheless there are cases dependent upon the .r-rav. Hofmeister calls attention to the possibility of error unless the tube is placed directly over the hip at a distance of about 23 inches, the patient being in the abdominal position with the limb rotated inward slightly or straight. In the differential diagnosis the forms of coxa vara following rhachitis, osteomalacia, ostitis fibrosa, osteomyelitis, tuberculosis, arthritis defor- mans, and traumatic separation of the epiphysis, must be excluded. The diagnosis is often very difficult. In rhachitis there are changes elsewhere in the skeleton. In arthritis deformans Maydl believes that there is a difference in the width of the two sides of the pelvis measured from the prominence of the trochanter to the middle line, the affected side being shorter, whereas in coxa vara the distance is greater. Curvature of the neck following a non-purulent inflammation of the hip-joint may be dis- tinguishable only by a very careful history, study of the general condi- tion and the .r-rav. Congenital or acquired dislocation is excluded by the history, and the fact that the head lies in the cavity and the centre of motion of the joint corresponds clearly to the cavity. Fracture of the neck or separation of the epiphysis comes in question only after trauma. Whitman, Sprengel, and Hofmeister have shown that only slight trauma is necessary, however, and that it may have occurred many years previously. Treatment. — If seen early, rest with continuous traction, massage, strengthening diet, and the administration of drugs influencing the pro- duction of bone may bring about a complete recovery. Usually the case is seen after considerable deformity has developed; even then the above COXA VARA. 517 measures may effect a satisfactory result, although the deformity per- sists. The pain due to the abnormal demands made upon the ligaments and muscles, analogous to that of the so-called inflammatory flat-foot, almost always yields to traction and massage, so that patients who even urge operation to alleviate the pain are relieved entirely in a few weeks and considerably improved. Haver claims that the shortening has been decreased by extension. Gymnastics arc particularly valuable: the author strengthens especially the abductors by active and passive motion, and has the patient exercise diligently with Krukenberg's "Pendel- apparat." Operation may be necessary if the deformity causes considerable impairment of motion and the latter persists after the pain has ceased. Simple tenotomy of the adductors (Zehnder), tenotomy with forcible correction (Vulpius), and osteotomy have been tried. Kraske prefers wedge-shaped osteotomy of the neck; Budinger does a linear osteot- omy; Lauenstein suggests division proximal to the trochanter; Miiller and Hofmeister favor linear subtrochanteric osteotomy. The author would recommend oblique subtrochanteric osteotomy, as in his ex- perience it has proved more satisfactory than cuneiform osteotomy of the neck. On account of the shortness of the neck one is liable to open the joint in operating on the former (Bardenheuer, Xasse, Hofmeister), so that the condition should be ascertained previously with the x-ray. Mikulicz claims good results by chiselling off the highest point of the curved neck; the projection is supposed to form the chief hindrance to abduction by striking against the upper margin of the cavity. Resec- tion of the joint is best for the severe cases. The improvement in the gait and general condition in the majority of cases of resection verify its value. (Miiller, Hoffa, Kocher, Maydl, Sprengel, and others.) In the case which the author resected, the shortening was reduced from 2f to 1-f inches. The importance of gymnastics and massage after the extension is removed is self-understood. Prognosis. — The pain in the acute stage, which usually keeps the patient in bed, finally disappears in most of the cases or is brought on only by overexertion, so that change of occupation is rarely necessary. This stage lasts either several months or several years; exceptionally attacks of pain occur even late in life. In regard to improvement in the faulty position of the limb, first the flexion, then the inward rotation, and finally the limitation of abduction disappears. The amount of improvement to be expected is often best estimated under anaesthesia. As in flat-foot, the disability may depend upon muscular spasm and not upon anatomical changes, the stiffness disappearing under anaes- thesia. Naturally one must exclude atrophic shrinkage of the mus- cles, especially of the adductors. The use of the limb increases as the muscular resistance diminishes. Changes also probably take place in the bone — that is, as the head is gradually absorbed, a new joint is formed between the acetabulum and the neck. The prognosis in general is therefore favorable. 518 DISEASES OF THE HIP. The Remaining Forms of Coxa Vara. — Besides coxa vara adoles- centium, which has been described more fully on account of its practical importance, there are a number of other forms of disease which may produce a varus deformity of the hip-joint. A series of individual observations were published some years ago; since then, more recently, all the affections concerned have been classified by Charpentier, de Quervain, and more particularly by the author's assistants, Alsberg and Wagner. A congenital deformity occurs associated with severe deformities in other joints. (Kredel.) The cause is supposed to be lack of space in the uterus. Kirmisson describes a hip-joint in a young child, the out- ward appearance of which somewhat suggested coxa vara, but in which in reality the deformity was due to a short posterior capsular wall hold- ing the limb rotated outward strongly. Zehnder reports a case of sup- posed congenital coxa vara which is very doubtful. The congenital form is apparently very rare. Congenital dislocation of the hip, espe- cially if of long standing, may produce a deformity of the upper end of the femur which after reduction may hinder abduction and require operation. A foetal specimen described by Wagner proves that a cur- vature of the neck may accompany intrauterine dislocation of the hip. Coxa vara rhachitica is not rare, although not so common as the rhachitic deformities elsewhere. In young children there is frequently an habitual outward rotation of the limb without impaired abduction. (wSchede.) It is not unusual to find the trochanter higher than normally and abduction considerably limited. In the majority of cases therefore the inclination angle of the neck is actually smaller; occasionally the condition may be simulated by curvature of the shaft just below the trochanter (Kirmisson); the a;-ray is conclusive. Kirmisson and Char- pentier, who have examined numerous rhachitic skeletons, state that the inclination angle of the neck is rarely diminished to any extent. Lauenstein in one case found the angle diminished on one side, greatly increased on the other. The relation of Goxa vara adolescentium to rhachitis is still undetermined. The deformity if slight may be corrected like other rhachitic deformities; if severe, in addition to general treat- ment, subtrochanteric osteotomy may be beneficial, as the author can attest from operation upon a bilateral case. Osteomalacia does not cause coxa vara as frequently as one would suppose. The author knows of only two authentic cases, one of Hof- meister's and another of Alsberg's. Equally uncommon is the varus deformity of acute osteomyelitis (v. Yolkmann, Diesterweg, Sehede, Stahl, Oberst, v. Brans, Honsell) and tuberculous coxitis (Kocher and others). A case of ostitis fibrosa with the deformity, reported by Kiister, is a pathological rarity. Arthritis deformans frequently causes coxa vara. It is important, as it is largely responsible for the early impairment of abduction. There is a certain tendency to self-compensation in the affection, the joint- surface being placed as obliquely as possible so that even if the inclination angle is greatly diminished, namely, the head lowered, the I ML AM MATH )S OF THE Ii URSJE A T THE Jill'. 5 1 9 direction-angle of the head does not appear to be decreased; hence, there is no actual varus position. This tendency can be utilized by abducting the Limb continuously and subluxating the head downward. Fracture of the neck, infraction, or separation of the epiphysis can produce the so-called traumatic coxa vara. 1 )c Quervain reports a case of coxa vara following fracture of the neck, which was resected success- fully by Kocher. Sudeck and Alsberg have shown that a static coxa vara can develop if strain is placed too soon on an infraction of the neck; the inflexion is naturally at the point of fracture. From the works of Whitman and Sprengel it is known that separation of the epiphysis is not uncommon in children even after slight trauma. The head may become reunited in a false position by bony union, with loss of the epiphyseal cartilage; it is rotated and displaced downward, the neck is bent backward, the limb is thus adducted and rotated outward. The picture clinically and with the a>ray is similar to that of coxa vara in adolescence. The differential diagnosis is especially difficult if the trauma occurred several years previously. Where trauma cannot be verified, the sudden onset, pain severe at first but disappearing rapidly, limitation to one side, and the absence of deformities elsewhere speak for the trau- matic origin. The disability is often marked ; the treatment is the same as that of the adolescent form. INFLAMMATION OF THE BURS.E AT THE HIP. Of the numerous bursae about the hip, variously estimated by Heineke as 14, by Synnestvedt as 21, the most important are the iliac and deep trochanteric. The iliac or subiliac bursa is about the size of a hen's egg in adults, and is situated beneath the iliopsoas muscle on the anterior surface of the pubis, below and to the outer side of the pubic spine. (Fig. 338.) It lies in the lacuna musculorum with the crural nerve to the outer side of the sheath of the femoral vessels, and may communicate with the hip-joint or be separated from it only by the synovial membrane. In- flammation and distention of the bursa may therefore affect the nerve. The bursa trochanterica profunda (bursa aponeurotica, or glutei maximi, or gluteotrochanterica) separates the gluteus maximus from the great trochanter, is rather large, simple or lobulated, and has three thin spots in the wall — behind, in front, and below — through which suppuration may perforate. The rare bursa trochanterica subcutanea lies over the great trochanter beneath the subcutaneous tissue. The bursa glutei medii corresponds to the position of the attachment of the gluteus medius on the tip and outer surface of the great trochanter. The bursa glutei minimi, corresponding to the insertion of the same muscle, lies on the inner surface of the tip of the trochanter. The bursa tendinis obiuratoris interni lies at the sciatic notch beneath the obturator internus as it emerges from the pelvis. A bursa vaginalis obturatoris 520 DISEASES OF THE HIP. interni is found infrequently between the tendons of the obturator interims and the gemelli. A bursa subcutanea is often found in the connective tissue over the anterior superior spine. A bursa iliaca posteriori is frequently found between the posterior ilac spine and the fascia. The bursa glut cot uberosa corresponds to the point where the gluteus maximus passes over the tuber ischii. As in general, acute, chronic, primary, and secondary inflammation of the bursa? may be distinguished. The secondary inflammations, especially of the iliac bursa, are important as the process may spread through a direct communication or indirectly into the joint. An abscess from the bone or joint may spread outward through the bursa or from Fig. 338. Rectus femoris. "Bursa of 1he :m gluteus mi dins. Bursa of the gluteus maximus. (B. troehanterica profunda.) Gluteus maxim us.— Bursa subiliaca superior. Bursa subiliaca inferior. —Ilcopsoas. Vastus c.i tenuis. Bursse in the hip. the opposite direction (spondylitis or pelvic abscess) into the joint. Primary bursitis, acute or chronic, serous or purulent, may follow wounds or contusions. Simple hygroma is most common On account of its exposed position the trochanteric bursa can be the scat of a hema- toma. The most frequent cause of bursitis is trauma, but the inflam- mation may be transmitted or follow an infectious disease (typhoid, septicaemia, gonorrhoea, syphilis). According to Petit, trauma is the cause in 57 per cent, of all cases, rheumatism in 15 per cent., icterus, cold, and puerperal fever each in 2 per cent., and in 32 per cent, the cause is unknown. Symptoms. — The inflammation at the onset is manifested by swelling and more or less pain, the swelling corresponding in general to the INFLAMMATION OF THE BURSJS AT THE 1111'. 521 position of the bursa, although it can be so extensive that it may be difficult to determine the point of origin. Cases of subiliac bursitis have been seen in which the tumor extended from Poupart's ligament to the middle of the thigh; similarly one of the bursa trochanterica profunda extending from the sacro-iliac synchondrosis almost to the inguinal vessels. BURSITIS of the subiliac bursa may give multiple swellings, for ex- ample, on either side of the iliopsoas with through-fluctuation. Fluctua- tion may be absent if the wall is thick or greatly distended; in the latter case it^may be mistaken for a solid tumor. Fluctuation otherwise unob- tainable, may be elicited by flexing the thigh. Transparency has been seen. The surface of the tumor is smooth. If dealing with a hygroma, the overlying skin and the tumor are independently movable. If the tumor presses upon the crural nerve, there may be shooting pains radia- ting to the knee. Compression of the vessels and venous thrombosis are very rare. The position of the limb is that causing the least pain and pressure upon the tumor, namely, flexion, abduction, and outward rotation; less frequently abduction and inward rotation. The corresponding muscles are contracted; motion at the hip-joint is limited but free under anaes- thesia. The mobility is important in the diagnosis against coxitis, as the latter may produce the same anomalous position. One thinks especially of coxitis if there is a suppurative bursitis with perforation or fistulas. Aside from the differential diagnosis already given under coxitis, flexion is less pronounced in bursitis. The fact that the position of the tro- chanter and the length of the limb are normal excludes all the affections in which the trochanter is elevated or the length of the limb changed. Echinococcus is excluded by the character of the contents of the bursa. Femoral hernia is usually excluded by the situation, direction, contents, and consistence of the tumor. Bursitis of the bursa trochanterica profunda gives a swelling above the trochanter on the outer side of the femur. If extensive, the gluteal fold may be obliterated. The tumor may be divided ij^to two parts by the muscles. The limb is flexed, abducted, and rotated outward, as in the iliac form, from the patient's effort to relieve the pressure of the glutei. The differential diagnosis from coxitis is as above; pressure at the trochanter is painful in both affections, but the extreme sensitiveness in front of and behind the joint in coxitis is absent in bursitis. The gluteal fold may be obliterated, and if suppuration occurs, the swelling may lie where one often meets with superficial abscesses from the hip-joint, namely, behind the trochanter. Fistulas often present in the same spot in both affections. In coxitis walking is often intensely painful, the reverse in bursitis. A blow upon the heel is painful in coxitis but not in bursitis. It may be difficult to exclude an ostitis of the trochanter, as pain, redness, and swelling occur in both affections; furthermore, the two affections may be coexistent, the one primary, the other secondary. Bursitis of the superficial trochanteric bursa is distinguished from inflammation of the deep bursa, according to Duvelius, by the fact 522 DISEASES OF THE HIP. that the tumor lies directly beneath the skin, and is not displaced by move- ments of the limb, while the swelling of the deep bursa slides backward in flexing the limb. According to Berend, the subcutaneous swelling is oval in the long axis of the limb, whereas the subaponeurotic swelling is a narrower, longer ellipsoid. The mobility of the tumor is limited by its position. The -kin is usually movable over it and normal; in the suppurative form it is infiltrated. The growth of the trochanteric hygroma is usually gradual, seldom rapid. The sciatic nerve is endan- gered if the tumor extends backward; cases are known in which it was infiltrated and displaced. A few cases of inflammation of the other bursas have been reported. Knowing the position of these bursas, inflammation of the same may be recognized by relaxing the muscles, pressing upon the bursa, and eliciting fluctuation, by palpating the surface, by aspirating, and by the history. Hygroma of the bursa on the tuber ischii occurs, according to Konig, especially in individuals who do hard manual labor while sitting. The .'*-ray is valuable in excluding affections of the bone. Prognosis. — The prognosis of bursitis as such is usually good if treat- ,t is begun promptly before a neighboring joint is involved. In spite of radical operation recurrence is occasionally observed, a new bursa forming and becoming inflamed if exposed to the same injurious influences. Treatment. — For hygroma compression combined with applications of tincture of iodine, inunction of blue ointment, or massage is often suffi- cient; even poultices or compresses of lead-water may be beneficial. If unsuccessful, aspiration followed by compression is useful. After aspira- ting one mav inject iodine, according to Velpeau. to excite adhesions and obliteration of the cavity, except when the walls are very thick, or there are multiple bursas, or it is suspected that the bursa communicates with a joint. It may be necessary to incise or enucleate the tumor. Suppuration demands immediate incision and preferably removal of the sac; or if too adherent, thorough scraping with a -harp spoon. The wound is drained or tamponed. INFLAMMATIONS OF THE INGUINAL GLANDS. Inguinal adenitis is a very common occurrence. The so-called indolent bubo of syphilis requires no special treatment. Painful inflammation of the glands occurs with inflammation of the genital.-, the inguinal region, and the lower extremities, the transmission of the inflammatory product through the lymphatics to the glands producing swelling and pain in the latter. The path of the inflammation is not always shown by a visible lymphangitis. For example, after small abrasions on the >r non-aseptic excision of bunion-, an inguinal adenitis sometimes develops without the characteristic, red, painful lines upon the limb. When the gland- are swollen the genital- should be examined for specific infection in the absence of other evidence. A primary bal- IXFLAMMATIOXS OF THE INGUINAL GLANDS 523 anitis due to ulceration may be the cause. The source of infection, a>, for example, in phlegmon or erysipelas, requires appropriate treat- ment. Severe abscesses frequently develop from inflammation of Etosenmuller's glands, situated between Poupart's ligament and the horizontal ramus. They should be excised radically. Treatment. — If the original source of infection is removed, large, even softened glands disappear entirely with rest and application of cold, pressure, iodine, or blue ointment. If purulent, the pus may be aspirated. But if the swelling invades the adjacent tissues, the skin becomes red and perforation is imminent: if only one gland is affected, it is incised; if the entire chain, it is best to remove them radically, avoiding the large vessels. If diseased tissue is left, protracted suppuration and fistula- may result. The wound should be packed with iodoform gauze and partially closed. Chronic oedema, sometimes swelling of the limb similar to elephantiasis, is occasionally observed after total extirpation. Welander and Spietschka have obtained good results by injecting hydrargyrum benzoicum oxydatum in non-specific adenitis; its use in the Berlin clinic is reported favorably by Thorn. A 1 per cent, solution is employed even if suppuration is well advanced, as the drug checks the process by causing the small suppurating foci to become rapidly confluent and by destroying the bacteria. Thorn reports 26 good results in 30 cases after one injection of 4 or 5 c.c. Lang's recent method consists in first injecting a 1 per cent, silver nitrate solution into all the pockets of the abscess through one or two small incisions, then drawing off the contents and covering the wound. This is repeated every two days till the contents become serous, then pressure is applied. CHAPTER XXV. OPERATIONS AT THE HIP. RESECTION OF THE HIP-JOINT. Resection of the hip-joint was first recommended by Charles White in 1769, after experimenting on the cadaver, and first performed by Anthonv White in 1821, through a curved incision above the trochanter. The method was named later after Velpeau, as he adopted it and recommended it widely. Jager, Roux, Textor, and Percy formed three- and four-cornered flaps; Sedillot made a curved flap with the base below. Subperiosteal resection was developed chiefly by v. Langenbeck. (Fig. 339.) With the patient in the lateral position and the thigh flexed, an incision 4 or 5 inches long is made from directly over the middle of the trochanter toward the posterior spine of the ilium. The fascia is split, the glutei divided in the long axis of the neck, all muscular attachments lifted subperiosteally from the trochanter while rotating the limb appropriately inward and outward, the capsule is divided, the ligamentum teres cut through with the limb flexed, adducted, and rotated inward forcibly, and the head dislocated and sawed or chiselled off. The method has undergone many modifications; Konig recom- mends saving the muscular attachments on the trochanter by chiselling off a front and a back bone-flap from the surface of the trochanter, the wedge-shaped piece of the trochanter left beneath being chiselled off squarely. Kocher makes a curved incision (Fig. 340) beginning at the base of the posterior surface of the great trochanter, from this point curving down- ward and obliquely upward toward the middle line behind in the direc- tion of the fibres of the gluteus maximus. The fascia of the gluteus maximus on the outer surface of the trochanter is split and the attach- ment of the gluteus medius and the periosteum of the trochanter exposed. The fibres of the gluteus maximus arc separated, or better the upper border of the muscle detached and drawn down. Between the lower border of the gluteus medius and the tendon of the piriformis the ten- dinous attachments arc separated forward from the trochanter to the subtrochanteric line, the capsule divided, the tendinous attachments separated subperiosteally backward on the trochanter, and the bone exposed. The further steps are the same as in v. Langenbeck's method. Tiling incises at the anterior border of the trochanter, chisels off the entire trochanter, and draws it backward, separates the capsule in front, removes the lesser trochanter, dislocates the head, and cleans out ( 524 ) RESECTION OF Till: HIP JOINT 525 the joint cavity. Sprengel gives a useful incision to expose the entire joint and the surrounding parts in old cases of extensive suppuration. 1 ' 1 "; Mlh \ lhe mcision runs along the posterior edge of the tensor fascue and curves backward at the anterior-superior spine along the ou ter border ot the crest of the ilium to the posterior-superior ipine- along the crest .. u carried down to the bone. The large flap of skin' muscles, and periosteum is turned backward and downward and the region of the joint freely exposed. At the close of the operation the Hap is sutured in place and the wound drain,,!. Sprengel's incision is tne transition to the incision opening the joint from in from. Tig. 339. Fig. Spmigd T. Langenbeck's incision for resection of the hip-joint. Sprengel' and Kocher's incisions for resection of the hip-joint. Roser recommends an anterior transverse incision in the direction of the neck for cases in which the limb is extended and abducted. Huter makes an oblique incision (Fig, 341) beginning midway between the anterior-superior spine and the trochanter and running downward along the outer border of the sartorius. The vastus externus is divided and the bone exposed; at the lower angle of the incision the external circumflex artery should be protected. Liicke and Schede use the ante- rior longitudinal incision for removing the head after injury. (Fig. 342. | It begins below and \ inch to the inner side of the anterior-superior spine, and runs from 4 to 5 inches directly downward; the inner border of the sartorius and the rectus are exposed and the muscles retracted 526 OPERATIONS AT THE HIP. outward; the dissection is carried bluntly to the outer border of the psoas and the muscles drawn inward. The thigh is then flexed, abducted and rotated outward, the capsule opened freely, the neck exposed and sawed through. The cotyloid ligament and teres ligament are divided and the head protruded. If sawed off, the head can be easily scooped out with a Willemer or Looker spoon-elevator. Konig chisels off the upper posterior margin of the acetabulum. In resecting for tuberculosis all infected tissue is thoroughly removed and the cavity cleaned out with the chisel. It will seldom be necessary to remove the entire acetabulum as done by Bardenheuer and Schmidt. The after-treatment is much disputed: the author does not recommend primary suture with or without drainage; recovery has always been uneventful if the wound was dusted with iodoform and tamponed with iodoform gauze. Secondary suture is superfluous. Suture, especially Fig. 341. Fig. 342. Hiiter'^ incision. I.ucke and Schede's incision. primary, frequently causes retention and subsequent protracted pain, fever, and suppuration. An aseptic dressing is placed over the wound and the edges approximated by a roller bandage. An extension splint can then be applied, or, better, the limb is abducted as in the extension splint, and a plaster splint put on, including the affected limb and the other thigh, the two thigh splints being united by a cross-piece to give stability. Sehede's table is most useful for this purpose, as the limb is most easily extended by its screw appliance. If recovery is uninter- rupted, the dressing is left from 8 to 10 days and then renewed through a large fenestrum cut in the plaster; later the wound may be drawn together with strips of zinc plaster. The author allows his patients to get up in the plaster splint in from two to three weeks and go about in a walking chair. Even if the extension treatment has been employed without a plaster splint, the author recommends that a well-fitting plaster splint be applied in about four or five weeks and the patient . 1 MI' I TTA TION A T THE MP- JOINT. r,27 allowed to be about. Taylor's apparatus is apt to produce an adduction position. A movable joint stable enough to carry the body is desirable, but not a loose joint. Quite a number of subsequently examined specimens of subperiosteal resection are reported in which a head was formed fairly well, either from the remaining portion of the neck or by a new growth at the lesser trochanter, and even covered with cartilage. (Kuster, Israel, Sack, Schede, Rose, Oilier.) A tendency to stiffness should not he combated too vigorously, but rather aided by immobilizing the limb slightly flexed and abducted, for a hip ankylosed in flexion and abduction is very useful and desirable. AMPUTATION AT THE HIP-JOINT. The so-called transfixion method formerly employed to obviate the danger of bleeding is not necessary with the present teehnic of con- trolling hemorrhage. Verneuil and Rose remove the thigh like a tumor, dissecting by layers and double ligating all large vessels as met. The method is equally commendable for tumors about the hip-joint, as the soft parts can usually be saved only partially. If possible, the incision is made so that the femoral artery and vein can be ligated at the outset, namely, through an anterior oval incision with the angle at about the middle of Poupart's ligament. To prevent loss of blood, Riedel advises ligation of the femoral vein at the close of the operation, not with the artery at the beginning. Larrey recommended preliminary ligation of the femoral artery and vein to diminish the loss of blood, but this has no influence upon the not inconsiderable bleeding from the branches of the internal iliac, obturators, and inferior and superior gluteals, or from the profunda if it is given off above the point of ligation. Biinger was the first to ligate the common iliac. Later Davy com- pressed it by means of a rod in the rectum. Trendelenburg recom- mended digital compression of the external iliac vein in addition to ligation of the common iliac artery. Rose ligated the common and internal iliac arteries and the external iliac vein ; the bleeding was slight, v. Esmarch proposed ligation of the common iliac vein and artery in difficult cases. As there was danger of partial necrosis of the flaps after ligation of the common iliac artery, especially the artery and vein, Schonborn advised temporary ligation of the common iliac artery. Braun compressed the internal iliac artery with the finger after ligating the external iliac artery ana vein. MeBurney proposed digital compression of the common iliac through an incision at the inner side of the anterior-superior spine. The aorta has often been compressed in thin subjects, v. Esmarch invented a compressor to protect the intestines from being bruised. The preservation of the soft parts, especially the muscles, is of the greatest importance for the application of a prothesis. If the soft parts about the hip-joint cannot be saved, the large vessels can be ligated pre- viously by one of the above methods and the amputation made almost 528 OPERA TI0N8 A T THE HIP. bloodless; an anterior and posterior flap are preferable. If the soft parts about the hip can he saved, high amputation is first performed and thru the head removed svbperiosteaUy. (Fig. .'>4o. I This method was first used by Vetch and Ravaton, and was especially recommended by v. Yolk- mann: The limh is first elevated, an Esmarch is then applied and tied firmly at the groin with a figure-of-8 turn around the pelvis to prevent slipping. Various complicated methods, mostly unnecessary, to prevent Fig. 343. Fig. 344. Kot i a -amputation method. slipping are given by Trendelenburg, Wyeth, and Senn. A circular in- cision is then made 6 inches below the tip of the great trochanter, all vessels are ligated, the femur ampu- tated, and the. Esmarch removed; the soft parts are then divided longitudi- nally down to the bone on the outer side of the femur, the periosteum lifted off with the elevator and dissected r>ff with the knife at the linea aspera externa and at the trochanters; the stump is then covered with gauze, flexed, abducted, and rotated in- ward with the left hand, the capsule incised along its back lower mar- gin, the cotyloid ligament cut through, the head dislocated, and the ligaments and capsule divided in front. Franke and Quenu, instead of removing the head, proposed to chisel it off at the neck and leave it. It was supposed to hasten recovery and improve the stumo. Incisions for amputation and exarticulation of the hip. (v. Winiwarter.) . i MI'UTATION A T THE HIP-JOINT. 529 Ktx-hcr'x " rc.s<<'iii)ii-amj>ntn" method was employed by bim in 9 cases with excellent results. (Fig. 344.) The incision is made the same as For resection; he then dislocates the head and separates the soft parts downward from the great trochanter in front and from the lesser tro- chanter behind. The attachment of the iliopsoas on the latter is divided. After appropriate ligation of bleeding points the limb is suspended ver- tically and a broad Esmarch tourniquet applied in a figure-of-8 around the highest part of the thigh and pelvis, the cross being behind and above the great trochanter. High amputation follows with a circular or oval incision, or with two short flaps, according to the amount of skin available; the skin is retracted and the muscles cut through smoothly to the bone. The covering should always be ample. After incising the periosteum it is lifted off bluntly from below upward and dissected off at the linea aspera. The bone is then sawed through, the femoral artery and vein, profunda artery and vein, saphenous vein, and all small vessels ligated and the tourniquet removed. The stump is then freed from all attachments subperiosteal^ and removed by twisting. The after-treatment is relatively simple. The flaps are sutured, drains placed at the proper points or a strip of gauze introduced. The prothesis is not made until cicatrization is complete. The mortality of hip amputation was 70 per cent, in the preantiseptic period (Liming), more recently 29 per cent. (Coronat), and even as low as 13 per cent. (Riedel). Vol. Ill —34 DEFORMITIES, INJURIES, AND DISEASES OF THE THIGH. CHAPTER XXVI. DEFORMITIES OF THE THIGH. Deformity Due to Rhachitis. — The deformity of rhachitis is usually a curvature convex forward and outward, that of fracture with malunion, an inflexion (angular deformity) forward and outward. Treatment. — Manual correction generally accomplishes little in either case, osteoclasis or osteotomy usually being necessary. Lorenz suggests combining open division of the contracted soft parts with one of the latter procedures. The limb is then immobilized, strongly abducted. The best results are obtained by not trying to overcome the abduction before six months or a year. Phocomelia. — Phocomelia, namely, partial or complete absence of the thigh, is a very rare malformation. According to Grisson, Lange, Lotheissen, Joachimsthal, Reiner, Blenke, and Drehmann, four varieties are distinguishable: 1. Shortening of the femur with coxa vara or congenital dislocation of the hip. 2. Division of the femur into several pieces; the lower end, head, and trochanter are present and isolated. 3. The same as 2, but the lower epiphysis is united to the tibia. 4. The shaft is very short, the hi]) and knee-joint being normal. Treatment. — The treatment consists in applying an appropriate prothesis. (Drehmann.) Maldevelopment of the Lower Epiphysis. — The deformity due to maldevelopment of the lower epiphysis is illustrated by a case of Nico- ladoni's: "The left limb is short and flexed at the knee. Flexion can be exaggerated till the calf sinks deeply into the well-developed muscles of the thigh. Extension is limited to 98 degrees, motion within the limit being strong and active. The knee-joint is apparently normal; the muscles or^the thigh, leg, and foot are apparently as strong as those of the other limb. The thigh and leg are both shortened; the tibia is curved, concave inward, chiefly at the spine; the head of the fibula lies about an inch higher than normally. The arrested development was due to trauma in childhood affecting the lower epiphysis of the femur and the upper epiphysis of the tibia. Walking was facilitated by a 10-inch stilt on the sole of the shoe." Deformity of the Lower End of the Femur. — Konig and Braun have recently called attention to a peculiar curvature of the lower end (530) DEFORMITIES OF THE THIGH. 531 of the femur, convex forward above the knee-joint. This developed within one or two years, and followed a flexion contracture at the knee, which in turn had developed six to ten years after the onset of the primary disease of the knee-joint, usually tuberculosis. The lower end of the femur was abnormally soft. The curvature was evidently due to changes in the epiphyseal line and in the disposition of weight, for the forces which, as a rule, produce a genu valgum with the knee extended, must necessarily product 4 a curvature of the femur in the sagittal plane when the limb is flexed. Treatment. -The use of the limb can be restored by an intraepiphyseal resection of the joint; to this Konig adds osteotomy of the femur. The deformities due to osteomyelitis will be discussed later. CHAPTER XXVII. INJURIES OF THE THIGH. INJURIES OF THE VESSELS OF THE THIGH. By reason of their suoerficial position the vessels of the inguinal region are greatly exposed to external injuries. So we meet with stab- wounds, incised, puncture, lacerated, and shot-wounds. The femoral artery may be injured alone, either the main trunk or one of its branches, or simultaneously with the vein. In fractures by direct vio- lence splinters of bone may injure the vessels. The brachial is the artery most frequently affected alone, then the femoral. The danger of fatal hemorrhage increases with the size of the wound in the artery. The bleeding from slight wounds of the wall is checked by coagulation or by the "wound canal" becoming shifted, as happens occasionally in puncture and shot-wounds. An imprudent movement of the arm may start up fatal hemorrhage, as is often seen upon the battlefield. If bright-red blood spurts from the wound and the opening in the artery can be seen, the diagnosis is simple. If the injured artery is not visible, the diagnosis may be difficult. The situa- tion of the wound and the cessation of the pulse in the affected limb are often deceptive if the wound is oblique and the pulselessness is from loss of blood. It is always important to compare the pulse in both limbs, although rapid dilatation of the collaterals can occasionally give a fuller pulse in the injured limb. v.Wahl gives as a diagnostic symptom of partial division of the artery a harsh, blowing murmur synchronous with the pulse — audible at the point of injury. If the femoral vein or one of its larger branches is injured, dark-red blood flows slowly but steadily. Dark blood spouting in a large stream during forced expiration also indicates injury of the principal vein. Hemorrhage from the venous branches often stops spontaneously or with temporary pressure, while hemorrhage from the main trunk is much more dangerous and usually requires operation. Wounds of the saphenous vein are of slight significance; pressure usually checks the hemorrhage. Treatment. — The first aid in wounds of the large vessels is strong digital pressure in the wound or against the pubis at Poupart's ligament. Later, ligation or suture of the vein or artery is indicated. Ligation should be at the point of injury if possible, whereas pressure is made more centrally, preferably against the ramus of the pubis. The artery may be compressed for wounds of the veins if one does not prefer to ligate the artery also, a procedure that has been carried out repeatedly to arrest venous hemorrhage. (Gensoul, v. Langenbeck.) The ligation should always be double, namely, above and below the wound, ar.d (532) 1SJURIES OF THE MUSCLES OF THE THIGH. 533 the injured portion excised, all lateral branches being carefully ligated before its removal. Marked dilatation of the smaller arteries after ligation of the femoral artery may cause secondary hemorrhage. To obviate this some surgeons prefer to ligate the external iliac. Porter recommends exposing and Ligating the artery through a transverse incision along l'oupart's ligament. Suture of the artery (arteriorrhaphy) according to Jassikoffsky, and as performed by Zoege v. Manteuffel on the femoral, should be tried in appropriate eases. Kiimmell proposes circular suture in proper cases. Suture of the vein is preferable if the wound is slight and severe hemorrhage and weak heart action jeopardize the development of the collateral circulation. (Jordan.) If secondary hemorrhage follows lateral suture, double ligation is indicated. The fear of air entering the vein and causing pulmonary embolism is unfounded; this only occurs in wounds close to the heart. Death from this cause in wounds of the femoral vein or after suture is not known. As to gangrene following ligation: the circulation is rapidly estab- lished through the collaterals after ligation of the femoral artery above or below the profunda, especially through the eirculus obturatorius. The conditions are less favorable if ligation of the femoral vein is necessary as the position and condition of the valves of the collateral veins appar- ently hinders the free return of blood to the heart. Formerly the limb was amputated at the hip-joint for fear of gangrene (Stromeyer, Pirogoff), Braune particularly having shown by experiment that the common femoral vein usually transmits all the blood to the abdomen It was found, however, that ligation of the femoral vein in extirpating tumors was not followed by gangrene. Eleven cases of this kind have been seen; the explanation is in the fact that the pressure of the tumor causes the gradual establishment of the collateral circulation. The later observations and experiments of Braune and v. Bergmann, Kam- merer, Niebergall, Trczebicky, Karpinsky, and Rotgans have proved that the femoral vein can be ligated without producing gangrene even in the absence of any tumor. If possible, the operation of ligating the femoral vein should be blood- less by applying the Esmarch. The wound should be packed and the limb suspended vertically to aid the venous flow and overcome the resistance of the valves, especially those of the circumflex iliac and obturator veins. Simultaneous ligation of the femoral artery and vein was followed in 12 of Kammerer's 22 cases by gangrene, and in 14 of Niebergall's 24 cases. Kageyama's statistics give gangrene in 39 per cent, of the cases of simultaneous ligation of the artery and vein in the extirpation of tumors and in 36 per cent, after ligation for trauma. INJURIES OF THE MUSCLES OF THE THIGH. Rupture of the Muscles. — Riders not infrequently suffer larger or smaller tears of the adductors. Maydl reports 7 instances of laceration 534 INJURIES OF THE THIGH. of the iliopsoas in which the tear was produced by overexertion, lifting heavy bodies, parturition, tetanus, or the attempt to prevent a fall backward. Two cases seen by Thiem were apparently associated with fracture of the transverse processes of the lumbar vertebrae. Maydl reports several cases of rupture of the biceps, one simultaneous with rupture of the semimembranosus and semitendinosus. The ruptures of the quadriceps are most interesting and important; they usually result from the effort to maintain an erect position in slipping or in mountain- climbing, the contracted muscle being stretched passively and torn by the sudden backward movement of the body. (Konig.) If the tear is situated in the rectus at the middle of the thigh, a depres- sion can be felt and above it the swelling of the retracted muscle. The patient may still be able to walk as a large part of the extensor apparatus is still intact. The full use of the limb is soon recovered, except that mountain-climbing is difficult on account of the weakening of the pelvic connection of the extensors. If the rupture lies lower in the combined tendon, the patella remains relaxed during extension as only the so-called reserve extensors attached directly to the leg are active. At first the function is greatly impaired; later the lateral muscles may become stronger and adequate. Treatment. — If the extended limb can be lifted in the dorsal position, massage and gymnastics are sufficient ; if elevation is impossible, incision and suture are preferable. Hernia of the Muscles. — By muscular hernia is understood in general a tumor-like protrusion of a portion of muscle through a tear in the fascia or muscular sheath. Exceptionally the tear in the fascia is pro- duced by sharp foreign bodies from without or splinters of bone in fracture; the protrusion is then not a pure hernia, as part of the muscular fibres are usually torn with the fascia. The most frequent cause is the pressure exercised by the contracting muscle upon the fascia. Farabeuf considers this pressure too slight to cause a tear. Aside from the anatomical inexactness of this view, one need only be reminded of the ability of many athletes to break iron chains by contracting the biceps to appreciate the pressure exerted by the contracting muscle upon its sheath, the essential being that the muscle contracts more quickly than the fascia can yield. According to Bardeleben, all the fascias of the body are attached to the muscles and are stretched by their movements. If the latter are inco-ordinated, the danger of tearing the fascia is increased. Under such circumstances it is not necessary to assume a certain brittle- ness of the fascia such as occurs in the aged. The favorite seat of hernia is the region of the adductors; Paradies found 15 cases, chiefly in cavalrymen, in the accessible literature. The effort of an untrained rider to keep his saddle causes sudden violent contractions of the adductors, thus tearing their sheath, which is one of the weakest parts of the fascia lata. In a case of Dupont's a bilateral hernia of the adductors followed sudden adduction of the legs in an effort to hold a heavy body between them. Radwitz reports a hernia of the semimembranosus, and Hartmann FRACTURE OF THE SHAFT OF THE FEMUR. 535 a hernia at the front outer side of the thigh after recovery of a compound fracture of the femur. Hernia of the biceps is also reported. The patients were all males, eighteen to forty years old. The tear in the fascia can rarely be felt, and there are apparently cases in which the prolapse is due to a local dilatation of the aponeurosis. Choux reports a radical operation of a hernia in which the aponeurosis was found intact. Guinard says that there are cases of apparent hernia which take place in thin uninjured spots of the muscle-sheath. According to this, the idea of muscular prolapse would include a localized stretching of the fascia as well as rupture. Treatment. — Compressing or elastic bandages never produce recovery. (Hess was the first to attempt a radical operation. Once recurrence followed removal of the prolapsed portion of muscle and simple suture of the skin, so in a later case he also sutured the freshened fascia and with success. Similarly, Sellerbeck, after excising the prolapsed portion of muscle, made three rows of buried sutures between the edges of the fascia and the muscle. The patient got up against orders on the seventh day, and recurrence followed. Choux did not remove the muscle, but made a purse-string suture about it with silkworm-gut after excising the dilated portion of fascia. Recovery was permanent after immobilizing for twenty days. As muscular hernia rarely gives marked subjective or functional disturbance, operation by the above methods will seldom be necessary. The discomfort at the outset soon disappears, a circum- stance worthy of note, with reference to accident and policy claims. FRACTURE OF THE SHAFT OF THE FEMUR. Fracture of the shaft is most common in workingmen, twenty to sixty years old, and in children, usually affects the middle third of the femur, less frequently the upper, and rarely the lower third. The cause may be direct or indirect violence or muscular traction. Direct violence must be severe to fracture the adult femur, and affects more particularly the lower third, as, for example, the weight of a falling body, runover accidents, gunshot fracture, Such fractures are apt to be accompanied by considerable laceration of the soft parts. Indirectly fracture results from falling upon the feet, and is then a bow fracture, the femur being bent beyond the limit of its elasticity like a stick held firmly at its upper end and pressed against the ground. Corresponding to its physiological curve the femur first breaks in front on the convexity, and is then pressed together at its concavity behind if the fracture occurs in the middle or lower third. If in the upper third close to the great trochanter, one finds a tear fracture outward and forward with the compression .behind and to the inner side, corresponding to the curve of the bone prolonged from Adams' arch. (Lossen.) Torsion fractnre is also produced indirectly, is usually situated in the upper third, and is dependent partly upon muscular action, as, for instance, the fracture caused by a misstep, or in bowling at the moment 536 INJURIES OF THE THIGH. in which the bowler in throwing the ball supports himself upon the limb in front and rotates the body upon it. This sudden rotation is the chief factor in producing the fracture. It is also produced some- times by a sudden movement to dodge a falling body or in rotating the thigh to reduce an old dislocation of the hip. Infraction is very rare. It occurs occasionally in adults, and is usually transverse without angular deformity. Fissures are very seldom seen in the shaft as independent fractures. Bouisson saw a case resulting from an oblique blow upon the hip in which the fissure, over 6 inches long, extended from the middle of the shaft to the external condyle. Complete fracture occurs in all the known varieties. Transverse fractures are confined chiefly to the epiphyseal line in rhachitic children Fig. 345. Fig. 346. Serrated transverse fracture of the femur in a child. iv. Bruns.) Spiral fracture of the femur. (v. Bruns.) or adults. Occasionally they are subperiosteal or the periosteum is partially torn. The surfaces are usually serrated. (Fig. 345.) The serrations may be engaged and somewhat impacted. Lateral dis- placement and angular deformity are usually slight. Oblique fractures constitute the great majority. The obliquity may be so pronounced that the fracture surfaces are parallel to the long axis for some distance; they may also be so smooth and sharp as to resemble the mouth-piece of a clarionet, hence the term "fracture en bee de flute." Spiral fractures produced by torsion, often by muscular traction, are characterized by the obliquity and sharpness of the fragments, one line FRACTURE OF THE SHAFT OF THE FEMUR. 537 of the fracture running in the long axis of the hone, the other in a spiral. Fig. 346.) It is most common in the upper end of the femur. Fissures are apt to radiate from both fracture-lines and extend to the adjacent joint. The sharp fragments may pierce the soft parts. Corresponding to the normal curve of the femur, the spiral usually runs from the lower inner side over the posterior surface upward to the outer surface. (Stetter, Mermillod.) Multiple and splinter fractures have nothing characteristic. The former are usually at the upper end with one fragment displaced, the Fig. 347. Spiral fracture of the femur with a typical i il splinter. Bruns.) shaft being divided into three large fragments. The middle fragment does not always include the entire thickness of the shaft uniformly, but is more often a wedge-shaped or rhomboid piece from the anterior sur- face. (Fig. 347.) In spite of the diversity of form, the nature and direction of fracture of the femur follow certain laws according as the break is in the upper, middle, or lower third of the shaft. In the upper third the fracture is almost alwavs oblique, the line running from above and without down- 538 INJURIES OF THE THIGH. ward and inward. In the middle third the oblique fracture also pre- dominates, but the line runs in the large majority of cases from above and behind downward and forward, either at an acute angle, at an angle of 45 degrees, or almost in the long axis of the femur. In the lower third, where the spongiosa begins and the corticalis becomes thinner, one meets with transversa but more often oblique fractures, a characteristic of the latter being that they are commonly oblique from above and behind downward and forward. In all these oblique fractures there is a tendency to overriding, and if the periosteum is torn, which is common, there is a somewhat typical dis- placement depending in turn upon the direction of the violence. The latter is, as a rule, applied from the outer side, and thus forces the lower end of the femur inward. Other factors are the curve of the bone and the traction of the muscles on the fragments. Rotation of the lower fragment about the long axis is common to all fractures of the femur, and is due to the weight of the limb. In fractures of the upper third the upper fragment is abducted and slightly flexed by the iliopsoas and the glutei. The lower fragment is displaced inward and upward by the violence and by the adductors. The fragments thus override and cross, and the limb is shortened. There is thus an angular deformity outward and forward at the point of fracture, distinct in thin subjects, in muscular or fat subjects occa- sionally concealed by flexion of the neck. (Roser.) The upper frag- ment may be splintered. (Bennet.) Displacement may be absent if the fracture is close to the trochanter, subtrochanteric fracture, even if the break is oblique. Nicoladoni refers this absence of displacement to the dense fibrous tissue forming the attachment of the muscles on the bone at this point. In fractures of the middle third the upper fragment is displaced for- ward and outward if the line approaches the upper third. If below the insertion of the adductors, the upper fragment is drawn forward and inward, the lower fragment outward, backward, and upward. In the lower third the upper fragment is drawn forward and inward by the adductors, occasionally so far forward that it penetrates the muscles and the bursa extensorum and lies beneath the skin or pierces it. The lower fragment is drawn upward and backward by the elastic retraction of the muscles. The occasional flexion of the lower frag- ment at the knee-joint, so that the fracture surface approaches the popliteal space, was referred by Boyer to the action of the gastrocnemii, by Lauenstein to a fall after the fracture. Symptoms. — If the fracture is incomplete or the periosteum partially intact, there are merely pain, swelling, and functional impairment. In the dorsal position, if the patient attempts to lift the limb angular deformity is noticeable at the point of fracture. False motion and crepitus are obtainable by shifting the fragments upon each other. If the periosteum is completely torn, the displacement and deformity are recognizable on comparing with the other limb. The foot and patella are always rotated outward. Shortening may be slight or even C inches if the fragments FRACTURE OF Till: SHAFT OF THE FEMUR. 539 override. The above symptoms are usually so pronounced that the diag- nosis can be made at a glance. If the site of fracture cannot be deter- mined, as in muscular patients, the examination can be made under anaesthesia and with the .r-ray. The latter gives the best information; two views should always be taken, anterior or posterior and lateral, to avoid deception. Prognosis. — The prognosis is generally favorable; even compound fractures, formerly so much dreaded, heal at the present time under aseptic measures. Bony union occurs in children in about four weeks, in adults in from six to eight weeks. Extension treatment promotes the rapid formation of callus, does not hinder the circulation, and over- comes the shortening most effectually. Formerly one was satisfied if a shortening of | to \\ inches persisted in the usual oblique fractures. v. Volkmann cites 110 cases treated by extension, of which 87 healed without shortening; in the other cases it was only T ^ to f inch. Fractures in the upper third unite in forty days with an average shortening of •§■ inch, in the middle third in thirty-two days with -^ inch shortening, and in the lower third in thirty-four days with \ inch shortening. (Hertzberg.) Pseudarthrosis is not very rare, and is usually attributed to marked overriding or interposition of muscles. In elderly individuals the possi- bility of hypostatic pneumonia and decubitus are to be borne in mind, and in very stout people the fatal fat-embolus. Serous or sanguineous effusion in the knee-joint is rather common in fracture of the lower or middle third, and is due either to the violence or to fissures extending into the joint. The effusions occurring later during the first attempts to walk are due to the fact that motion acts like a sprain upon the dry and rigid joint, (v. Volkmann.) Effusions of the latter sort often persist for some time; the former variety are usually absorbed during recovery. The later usefulness of the limb depends upon the treatment. The accident statistics of Haenel are interesting. Of 121 fractures of the femur, only 39 recovered fully, in 75 the injury was permanent with an average loss in earning-efficiency of 28 per cent. The average period of complete recovery was thirteen and one-half months. The results were bad in direct relation to age. The most frequent causes of functional impairment were shortening and stiffness of the knee-joint. Muscular atrophy, exuberant callus, pain, pseudarthrosis, and decubitus also played an important part. Treatment. — While the pelvis and when possible the upper part of the femur are steadied by an assistant, reposition is effected by grasping the foot with both hands, lifting the limb carefully and fully, and rotat- ing steadily with increasing traction until the long axis of the metacarpal of the great toe, the inner border of the patella, and the anterior-superior spine are in a straight line. If the fracture lies in the upper or middle third, the limb should be abducted till the fragments are apposed. Impalement of the soft parts is sometimes recognizable by a pitting of the skin at the corresponding spot. In such cases interposition takes place easily, and the impalement should be freed either by rotating or 540 INJURIES OF THE THIGH. through a small incision. Reduction is most easily effected upon a Schede table or with v. Bruns' apparatus. The various immobilization splints and apparatus formerly used often did more harm than good, and are replaced at the present time by position-, strip-, and plaster-splints and continuous weight-extension. Temporarily the patient may be placed in the so-called Pott's lateral position, namely, upon the injured sick- with the knee and hip flexed and the limb steadied between sand-bags. This is especially useful in those instances in which the upper fragment is flexed, but is uncom- fortable if prolonged. In the dorsal position a double inclined plane may be used similar to that of v. Esmarch. For transportation, especially of delirious patients, one of the various strip splints is necessary, either Bonnet's woven-wire splint or a strong outer splint, the width of the hand, extending from the pelvis to the foot. It should be well padded at the pelvis, knee, and foot, and have Fig. 348. Helferich's extension splint. a cross-piece at the foot to prevent rotation. A thick pad should be laid against the outwardly displaced fragment. To this v. Esmarch added extension by means of adhesive-plaster strips, a spreader, an iron hook and elastic band at the foot, and counterextension by means of a perineal band. Smith's anterior wire splint, made in an emergency, of telegraph wire, and as used to advantage for shot-fractures in recent w T ars, is also serviceable. Roser suggests a gutter splint of three pieces that can be drawn out to any desired length. A plaster-splint should include the foot of the affected limb, the pelvis, and the upper half of the sound thigh. Its disadvantage is the subse- quent loosening due to atrophy or diminution of the swelling. Even if accurately applied immediately after injury, slight lateral deviation and thereby increased shortening are unavoidable. It should never be applied if the soft parts are greatly swollen, as gangrene of the entire extremity may result. In applying the splint the patient should be FRACTURE OF THE SHAFT OF THE FEMUR. 541 placed upon the pelvic support (v. Volkmann, Bardeleben, v. Brims, Schede), the fracture bandaged first, and then the adjacent joints. Continuous weight-extension as employed for fracture of the neck is by far the best method. A pillow should be placed under the knee to prevent hyperextension and pain. The marked abduction and flexion of the upper fragment in fractures of the upper and middle third are overcome by abducting the limb upon an inclined plane. Lateral traction may be necessary to overcome pronounced inflexion. Ilel- ferich's method is shown in Fig. 348. It is important to inspect the limb constantly to prevent decubitus and to maintain the proper position. It is also important to measure the length of the limb from time to time, comparing it with the sound limb. (See Fracture of Neck.) Fig. 349. Schede's method of vertical suspension. Extension is counterindicated for fractures close to the knee-joint as the ligaments are easily overstretched, v. Volkmann's T-splint, or, better, v. Bruns' new splint, is useful, especially for transverse fracture without much displacement. If displacement exists, extension is applied for from eight to twelve days and then replaced by a plaster-splint. Beely and Treves recommend flexing the knee and suspending the limb if it is desirable to overcome the displacement at the outset. This is impossible if the soft parts are much swollen or there is an effusion of blood in the 542 IX JURIES OF THE THIGH. Fig. 350. knee-joint; Bryant therefore proposes tenotomy of the Achilles tendon to relax the gastrocnemii, the cause of the displacement. Treves did this in 3 cases, later using weight-extension. Suspension and extension may be combined satisfactorily by using Beely's plaster- and hemp strip- splint. If the patient is restless, it should include the pelvis. In young children immobilization was formerly very difficult on account of the character of the soft parts of the thigh and the fulness of the abdomen. A plaster-splint or even three-piec? strip splint with a long outer strip is badly borne, as the skin is always soiled beneath and eczema and excoriation produced; Schede's vertical suspension obviates this. (Fig. 349.) A weight of 4 to 8 pounds is sufficient. The method gives great comfort; the child can be kept clean, and union is rapid, usually complete in about three weeks. It is not necessary, as recommended by Lentze, to enclose the foot and leg in plaster. In fact, this is apt to produce necrosis of the skin. For fracture of the neck acquired during delivery the thigh may be flexed upon the abdomen and held by adhesive strips encircling the body. This allows the child to be bathed and cleaned. After union has taken place and ex- tension is removed, as the callus is still soft and may bend or break, a remov- able silicate-splint should be applied and the limb strengthened by methodical massage and gymnastics. The ambulant treatment, which has recently won many advocates, should be mentioned, although the extension splint is unquestionably most worthy of re- commendation for the practising sur- geon. Hessing was the first to employ the ambulant treatment successfully for recent fractures of the leg and thigh. He first put on a glue dressing, and over this applied a sheath splint apparatus constructed over a wooden model, and which exercised continuous traction and held the fragments in position. (Fig. 350.) On the same principle splints have been made and recommended by Dombrowski, Reyher, Selenkow, Thomas, Harbordt, Heusner, Lier- mann, and v. Bruns, but they are not so complete as Hessing's, although doubtless of value in the hands of competent surgeons. v. Bruns' combination ambulant and bed-splint (Figs. 351 to 354) is the most serviceable for general use. It consists of two side rods, a Hessing's ambulant splint. FRACTURE OF THE SHAFT OF THE FEMUR. 543 perineal ring, and a foot-brace. WheD recumbent, the limb rests upon several broad linen strips stretched between the rods, which latter are adjustable. ( )ver the front are fastened several narrow straps. Taking, for example, a fracture of the middle third, the splint is first used as an immobilization splint with traction for two or three weeks. Strips of adhesive plaster are fastened on both sides of the limb and attached to a spreader, to which a cord and weight are fastened. (Figs. 351, 352.) The extension is removed in about three weeks, a light plaster- of- Paris-splint applied from the toes to the groin, and the frame adjusted over it as an ambulant splint, the foot-board being removed and the Tig. 351. v. Bruns' combination bed and ambulant splint. brace so applied under the foot that the adhesive straps can be drawn down and tied to it to exert traction, countertraction being effected by the perineal ring against the tuber ischii. (Figs. 353 and 354.) Trac- tion is only necessary for oblique fracture ; in simple transverse fracture the splint may be made portable from the first. Korsch, Albers, and Dollinger have recently attempted to simplify the ambulant treatment still further by using a plaster-splint alone. Korsch applied it, as in fractures of the leg, directly over the shaven skin with- out any padding, the splint, extending from the midtarsus to the hip, exerting pressure against the malleoli, dorsum of the foot, and heel, and 544 INJURIES OF THE THIGH. above against the tuber ischii by means of a perineal pad made of wire and sheet iron. Albers' method was similar. Dollinger's method is very useful: The splint is put on in two parts; a thick cotton pad is laid against the sole of the foot and the plaster-splint moulded over the foot, leg, and lower third of the thigh, fitting closely about the ankle and the condyles of the femur. The patient is then carefully placed in a Sayre frame with a block 1 to H inches thick under the sound foot. The foot part of the plaster-splint is fastened to a hook screwed in the Fig. 353. Fig. 354. v. Bruns' splint when ambulant. floor. A pad of plaster-of-Paris is incorporated in a long linen strip and placed under the tuber ischii, the ends of the strip being tied together above the brim of the pelvis and caught in the hook of the suspension pulley. The limb is then lengthened appropriately by raising the patient. The pelvis and thigh are then encased in plaster blending firmly with the lower splint. With a high sole on the sound foot the patient goes about with crutches or a cane. Dollinger's results are very good. Also those obtained by Graff upon Schede's material. According to Graff, FRACTURE OF THE SHAFT OF THE FEMUR. 545 energetic extension is of first importance, and Sehede's table is well adapted to this end. He advises immediate application of the portable splint only where the swelling and displacement are slight. Fig. 355. Buck's extension with a Yolkmann sliding rest. (Stimson. i Fig. 356. Hodgen's suspension splint. (Stimson.) Vol. III.— 35 546 INJURIES OF THE THIGH. [The methods most widely used in America are Buck's extension and Hodgen's suspension, which hardly need further description here than that given in the accompanying figures.] The author recommends the ambulant treatment only to very expe- rienced surgeons. In less skilful hands it may do great harm; angular union is unfortunately not a rarity if the extension or plaster-splint is improperly applied. If a fracture with angular union is still pliable, it may be refractured ; otherwise oblique osteotomy and forcible extension have been shown by experience to be most practical. To cure a pseudarthrosis of the femur, all the available measures extant have been used. The author has repeatedly effected a cure by allowing the patients to go about in a well-fitting sheath splint, the constant irritation stimulating the necessary formation of callus. If union is prevented by interposition of muscle, the fracture-ends should be exposed subperiosteal^ 7 , freshened, and fixed either with ivory pegs, steel screws, silver wire, by Sick's method of screwing on ivory plates, by ParkhilFs silver-plated screws and plates, or by rabbeting and nailing the fragments as done by v. Volkmann. To stimulate bony union the patient should go about in a supporting apparatus as soon as possible. GUNSHOT-WOUNDS OF THE THIGH. The introduction of small-calibre firearms and antisepsis have so changed the conditions of gunshot-wounds of the thigh that the expe- rience of previous wars no longer applies, so that in the following only the observations made by Kiittner in the South African War will be considered. Gunshot-wounds of the thigh are very common, perhaps slightly less so than formerly, possibly due to the fact that modern warfare is more protracted and carried on less in the open on account of smokeless powder and the greater range of modern weapons. Wounds of the soft parts are especially frequent as the muscles of the thigh are very thick and the small-calibre bullet reaches the bone less easily than the larger projectiles. Wounds of the soft parts show a distinct tendency to primary union on account of the smallness of the opening and of the track. Very long tracks are sometimes found, the wound of entrance at the knee, the wound of exit in the hip; the bullet not infrequently lodges. Large wounds of exit are produced only by shots at short range from the action of the powder gas ; they are very similar to the wounds of exit made by the partially coated (lead tip or Dum-Dum) bullets, large areas of skin and muscle being extensively lacerated and shat- tered. In recent wars schrapnel wounds were numerous, the bullet frequently carrying pieces of cloth with it and lodging and producing infection. The wounds made by heavy ordnance and secondary projectiles are very diverse. After the battle of Magersfontein severe wounds of the soft parts were seen which were produced by pieces of rock hurled GUNSHOT WO USDS OF THE THIGH. 547 about by the projectiles, also extensive burns made by metal fragments ami kernels of powder from bursting shells. Wounds of the vessels and nerves are more often slight on account of the flat trajectory and the small calibre of the bullet. Wounds of the femoral artery more frequently cause aneurism than formerly, as the blood finds its way out less easily through the narrow track. The sciatic was often involved, usually only partly torn, occasionally split, and repeatedly followed by neuritis. Gunshot-fractures of the femur are perhaps the most important of all gunshot-wounds on account of their frequency and the difficulty of their treatment. The shaft is more often affected than the epiphysis. In the Franco-Prussian War the shaft was affected in its upper third in 29 per cent., in the middle third in 20 per cent., in the lower third in 26 per cent., and in an indefinite situation in 25 per cent, of the cases. Knowledge of and interest in fractures made by small-calibre bullets have been greatly increased in recent wars by the a>ray. Kiittner and Makins have published a series of pictures ranging from simple oblique fracture to very extensive splinter' ng. Splintering (comminution) is the rule in fractures of the shaft made by metal-coated bullets, the zone at all ranges being the same, 4| to 5j inches. At close range the splinters are usually small, at long range large ; the largest observed in the femur was h\ inches long. The typical form is the "butterfly-fracture" with extensive shattering. (See p. 139.) The bullet not infrequently breaks into fragments or lodges in the soft parts; effusion in the adjacent joint is very common. The wound of exit is usually small, even at close range, not being more than 1 to 1^ inches deep and f inch wide. Wounds of the epiphysis are less serious than those of the shaft. Round-hole perforation without splintering has been seen at either end of the femur; round-hole wounds of the tro- chanter may behave almost like an ordinary wound of the soft parts. Extensive comminution of the epiphysis occurs only at short range, and is especially dangerous on account of the proximity of the joint. Prognosis. — The prognosis of gunshot fractures of the thigh depends upon the extent of involvement of the soft parts more than upon the damage to the bone; also upon the treatment and external conditions. In respect to the latter, transportation is significant, early and long transportation decreasing the chances of aseptic recovery. Under the proper circumstances and care the severest splintering may heal if the skin-wound is small and no infection occurs. Delayed union and refracture are possible and pseudarthrosis is not very uncommon. Treatment. — The treatment should be as conservative as possible. Primary amputation will be considered only for extensive shattering as produced by close-range shots, bomb-shell fragments, partially coated bullets, and secondary projectiles. Fractures produced by metal-coated bullets require simple occlusion of the wounds and careful immobiliza- tion on the battlefield. A plaster-splint that includes the pelvis is best, although a long outer splint may be used in an emergency. Under auspicious circumstances the plaster-splint may be left on till union is 548 IS JURIES OF THE THIGH. complete; if the patient is transferred early to a hospital, extension should be applied. Suppuration demands free exposure and cleansing of the fracture area, removal of loose fragments and foreign bodies, counteropening, and drainage. Secondary hemorrhage is dangerous and usually requires amputation. Amputation should also be done promptly if general infection is imminent. CHAPTEK X X VIII. DISEASES OF THE THIGH. DISEASES OF THE SOFT PARTS OF THE THIGH. Aneurism. — Aneurism of the femoral artery is four times less frequent than that of the popliteal; Delbet has collected 35 eases. Trauma is the usual cause, although it is certain that diseases of the arterial wall, particularly endarteritis or congenital weakness of the tunica media, often act as predisposing causes. Not infrequently multiple aneurisms are met with along the artery; Lowe, Scarpa, and Monro report cases of three or four along the femoral artery. In Scarpa's triangle the aneurism is usually round, but farther down it is more spindle-shaped. The femoral vein is seldom compressed. (Edema of the limb is less common than in popliteal aneurism. Occasionally pain, twitching of the muscles, and formication develop. As in all other aneurisms, the dilatation is gradual; spontaneous recovery happens occasionally. If the aneurism is in a lateral branch, as is sometimes the case, the diagnosis mav be difficult if the tumor cannot be distinguished from the femoral artery. The pulse, however, of the posterior tibial is unchanged unless the main trunk is affected. Endogenous aneurisms are most common in the upper third of the thigh, and grow larger than in the lower third, where the sartorius prevents their development some- what. They are easily confused with cold abscesses or gra vitation abscesses. Treatment. — Compression should be tried first, either digital, or with an elastic bandage, or the attempt made to produce clotting by means of a pad and bandage when the position of the aneurism is favorable. In applying an elastic bandage the limb should be elevated vertically and bandaged from the foot upward; the second bandage is then applied over the aneurism, the first removed, and the former left on for about an hour and a half; after removing it digital pressure is renewed and continued as long as possible. (Reid.) Delbet saw fairly good results from compression: 76 recoveries in 111 cases; in 5 the aneurism rup- tured. Ligation or extirpation is indicated if compression fails. Delbet cites 17 recoveries in 30 cases after ligation; in 2 cases an aneurism developed later at the point of ligation. Gangrene occurred in 4, in 3 of which the aneurism was diffuse. Excision gives better results than ligation. The operation is often difficult, as the femoral vein especially has to be protected and avoided if possible. As stated previously (see Injuries of Vessels of Thigh), simultaneous ligation of the femoral (549) 550 DISEASES OF THE THIGH. artery and vein is not necessarily followed by gangrene. The teehnic of excision of an aneurism is practically the same as the operation for injuries of the arteries. Arteriovenous aneurism is not infrequently met with in the thigh, and usually develops from wounds produced by sharp instruments or pro- jectiles. Such have been recently described by Konig and Thiel; one of these was situated in the middle of the thigh, and was removed by v. Bergmann under application of the Esmarch after double ligation of the femoral artery and vein above and below the tumor. No bad results followed. In Thiel's case the aneurism, beneath Poupart's ligament, could be removed only after double ligation and division of the external iliac artery, the femoral artery and vein below the tumor, and the external iliac vein and profunda artery and vein. Recovery was complete. Varicose Veins of the Thigh. — Varicosities of the cutaneous veins of the thigh not infrequently develop as the result of engorgement of the venous circulation of the thigh, especially in multiparas or individuals whose occupation compels them to stand, walk, or ride horseback a great deal. The bluish, sacculated, and tortuous appearance of the superficial veins is well known. The saphenous vein especially shows marked dilatation from the falciform process to the knee. (See Plate XVIII.) Rupture sometimes causes fatal hemorrhage. Occasionally one sees periphlebitis, suppuration, thrombosis, with or without calcium deposits, and phleboliths. Treatment. — Compression by means of elastic stockings or bandages should first be tried. If unsuccessful, excision (Madelung, Casati), or, better, Trendelenburg's ligation of the saphenous vein is indicated. The results of operation are very satisfactory. (Faisst.) The saphenous vein is exposed, double ligated, divided, and the intervening piece of vein removed. Recently Wenzel warmly recommended a circular inci- sion around the thigh. Lymphangiectasis. — Dilatation of the lymphatics, as, for example, after total extirpation of the inguinal glands, may lead to elephantiasis. If of long duration, there may be hyperplasia and great thickening of the skin and subcutaneous tissue. Rupture, fistulas, and lymphorrhcea may follow. Treatment. — The treatment is the same as that of varicose veins, but the prognosis is less favorable. Thermopuncture often gives the best results. In elephantiasis excision of ellipsoid-shaped sections of skin and ligation of the femoral are also recommended; the results are said to be favorable. Riders' Bone. — An osteoma occasionally forms in the adductors of riders. Usually the cause is the constant irritation of the saddle. The process is most frequently an inflammation of the muscle leading to the formation of bone. It may be due, however, to injury of the muscle at its origin resulting in the growth of the periosteum along the course of the adductors, or a piece of bone may be chipped off by trauma and continue to grow in the muscle. The growth has also been found in the INFLA MM A TOR V PROCESSES IN THE FEMUR. 551 pectineus, vastus, and gracilis, [f the muscle is relaxed, the formation can be felt as a hard mass, varying from 1 to 6 inches long. It may develop in two weeks. Ludwig reports :! eases of osteoma in the vastus externus of the left thigh of cavalrymen. They were due to the Mows of the sword-hilt upon the outer side of the thigh during 1 ng gallops Upon horses with hard hacks. Treatment. — Cases are reported in which the growth diminished or disappeared, if not too large, under massage and w -t compresses. In others, inunctions of iodine ointment or ek'ctropuncture were successful. Excision is most certain, hut may he difficult as the growth is usually embedded in thick, dense connective tissue. Sciatica. — Ischias (that is, neuralgia of the sciatic nerve) is charac- terized by pains radiating from the thigh to the calf. Typical painful points are found at the exit of the sciatic plexus from the great sciatic notch, about the tuber isclhi, on the posterior surface of the thigh, in the fold of the buttock, helow the head of the fibula, and behind the internal malleolus. The cause is usually an acute 1 inflammation of the nerve-sheath with adhesions and thickening following a cold. To prevent the pain, the limb is guarded and movement carefully avoided. As a result of this effort to protect the painful spots contractures are not rare, of which the author would emphasize the peculiar constrained position of the body termed ischiatic scoliosis. Treatment. — The treatment consists chiefly in massage, gymnastics, and electricity. The back of the hip and thigh are massaged twice daily and active motion and finally passive motion are carried out to stretch the nerve as much as possible and loosen any adhesions. This procedure is very painful at first, but the affection yields rapidly, so that even in old cases recovery can be brought about in a few weeks. Stretching the sciatic nerve is usually very beneficial. The thigh is flexed as far as possible with the leg extended, or the leg is alternately flexed and extended as far as possible with ilie 'high flexed. The patient should walk as much as possible during the treatment. Electricity, baths, and daily stool are valuable aids. Morphine is often necessary; subcutaneous injection of cocaine or antipyrin into the nerve often give great relief. Operative stretching of the nerve 1 is indicated for severe cases resisting conservative treatment. Ilolscher has recently recom- mended exposing the nerve as it emerges from the pelvis and applying wet compresses of 5 per cent, carbolic-acid solution for several days. The result is said to be good and permanent. INFLAMMATORY PROCESSES IN THE FEMUR. Acute Osteomyelitis. — Acute " spontaneous " osteomyelitis, according to Haaga's statistics of 440 cases in v. Brims' clinic, affects the thigh in 39 per cent, of all cases. The site of choice is the lower (aid. Accord- ing to Lexer's recent investigations, it is commonly a staphylococcus, less frequently a streptococcus infection. Staphylococcus aureus or ulbus is 552 DISEASES OF THE THIGH. found in the mild cases; the streptococcus alone or with the staphylo- coccus in severe cases. The point of entrance of the bacteria is either a small suppurating wound, acne pustule, furuncle, panaritium, eczema, abscess, etc., or an abrasion in the mucous membrane of the mouth or nose, especially an inflamed spot in the nose or on the tonsil. This point of entrance is unknown in only a small percentage of the cases; it is then supposed to be in the respiratory or intestinal tract. Recently Ponfick has shown that infection may occur through the mucous mem- brane of the middle ear. Trauma unquestionably plays an important part, as bacteria settle chiefly in bruised tissue, the point of least resist- ance. The disease occurs most frequently between the eighth and seventeenth years, the period of most active growth, and is rare in early childhood or middle life. Men are more commonly affected than women (4 to 1). Symptoms. — The symptoms are those of a severe septic infection, and vary according to the intensity of the process. In acute cases there is usually an initial chill and rapidly increasing severe pain, swelling, and high continuous fever: in the morning 102.2° to 104° F., in the afternoon 104° to 105.8° F. The swelling increases rapidly and becomes cedematous with a diffuse redness about the hip. Gradually superficial fluctuation develops, and spontaneous rupture occurs, as a rule, in about fourteen days. The local symptoms ordinarily point early to a disease of the bone. On the other hand, if the patient is in a condition of complete stupor, typhoid may be suspected until the local symptoms are distinct. Con- fusion with severe phlegmon is less possible, as in osteomyelitis the uniformly hard cedematous swelling, surrounding the entire hip and disappearing very suddenly, is characteristic. (Konig.) If less acute, a rapidly growing tumor or tuberculosis may be suspected. Kiittner has recently called attention to the occurrence of a primary tuberculosis of the shaft. From its proximity to the joint there is almost always an osteochon- dritis of the epiphysis followed by inflammation of the joint, either serous or purulent, or separation of the epiphysis. Foci in the epiphysis may perforate directly into the joint or even through the knee-joint into the tibia. The severest cases, with fever like that of typhoid, severe septic infec- tion, separation of the epiphysis, suppuration of the knee- or hip-joint, and involvement of a large part of or the entire shaft are almost always fatal. Almost regularly part of the bone is destroyed and a sequestrum formed. The separation of the periosteum and purulent infiltration of the medulla cause more or less extensive necrosis of the bone, either superficially in plates or scales (cortical sequestrum) or of large portions of the compacta and spongiosa. Often the entire thickness of the shaft becomes necrotic and the whole shaft forms a sequestrum (total necrosis), or there may be multiple spots of necrosis (necrosis dis- seminata). (Fig. 357.) The larger sequestra generally separate in about three months. The separation of the sequestrum, although INFLAMMATORY PROCESSES IS THE FEMUR. 553 often difficult to determine, is presumed it* the granulations bleed easily. It may not be possible to move the sequestrum with the probe if it is held by points projecting into the wall of the bone. A peculiar sound, cracked-pot, as Konig calls it, may be elicited by probing. Fig. 357. vj- Fig. 358. Necrosis of the femur at the typical spot, (v. Bruns.) General necrosis of the femur with numerous fistulas. (v.Yolkmann.) The separation in some cases is determined by the .r-ray, in others only on operation. (Fig. 358.) Removal at the proper time is very important: if undertaken too early, the formation of new bone may be limited and pseudarthrosis or spontaneous fracture may occur; on the other hand, long-continued suppuration may cause chronic nephritis and amyloid degeneration of the viscera and death. The fistulas usually open outward between the vastus externus and biceps, or between the vastus interims and the adductors. The deformities are very interesting. The shaft may be bent at the upper or lower end or in the middle. At the upper end it may resemble coxa vara if the neck is involved. The deformity may be marked. (Fig. 359.) The lower end is apparently more frequently affected, as in the cases reported by Oberst, Kraske, Mosetig, Bofinger, Braasch, 554 DISEASES OF THE THIGH. Birch and Hirschfeld, Karewski, and ScharfT. In all these cases there was a very characteristic curvature backward or inward about 3 inches above the joint; the sequestrum was central, as verified by the x-ray, and usually without suppuration and perforation. The deformity is due apparently to muscular action and the weight of the body. The proliferation of bone may produce complete sclerosis, or, if old abscesses persist, club-shaped enlargements of the shaft. The epiphyseal growth may be stimulated and the femur lengthened. The discharge of large sequestra may produce shortening. Total necrosis of the entire shaft causes the greatest deformity, with shortening and an abnormal position of the lower portion of the limb. Fig. 359. Curvature of the upper end of the femur. (Oberst.) Treatment. — Usually the treatment is purely surgical. At the onset, aside from general measures, stimulants and nourishing diet, absolute rest should be enforced, the limb immobilized with a strip splint, and ice applied to diminish pain. Early drainage should be secured by free, and if necessary, multiple incisions, and the bone examined carefully. If the periosteum is intact, the wound is simply drained ; if the periosteum is lifted off by pus and the exposed bone beneath is filled with yellow spots, the latter should be incised as far as diseased, the diseased medulla scraped out, and the cavity packed with iodoform gauze. If this is done in time, necrosis and involvement of the joint may be prevented. The sequestrum should be removed under application of the Esmarch. The bone is exposed through a free incision and opened either by widen- ing the existing opening or by chiselling off a sufficiently large "lid" of the "coffin" to expose the sequestrum. Often considerable bone has to be cut away in order to seize and extract the sequestrum. If the seques- trum is large, the walls of the "coffin" should be chiselled away till TUMORS OF THE THIGH. 555 every part of the cavity is exposed and can be thoroughly cleansed of sequestra, granulations, and pus. Although this often makes very large hone cavities with sloping walls, into which the soft parts are implanted with difficulty, and which require a long time to heal over, nevertheless the method is usually successful. (See also p. 702.) The implantation of organic or inorganic material has not given very good results. Small cavities may be blood-clotted by Schede's method. Recently Schulten recommended implanting a pedunculated muscle- periostenm flap after careful removal of all granulations. If the seques- trum is in the lower epiphysis, Liicke implants the patella. If the process is close to the knee-joint, in spite of all treatment fistulas may persist and amputation be necessary to prevent a fatal termination of the suppuration and cachexia. TUMORS OF THE THIGH. Tumors of the Femur. Cystic Chondrofibroma.— Of the tumors of the thigh, those of the femur have recently claimed the most attention, especially since the in- vestigations conducted under v. Bergmann. Surgeons have thus become familiar with the nature and diagnosis of a class of tumors formerly little regarded, but extremely significant for the differential diagnosis, the cystic chondrofibromata. These tumors vary greatly in size, but their situation is constant and significant for the differential diagnosis. Thev usually start close under the trochanter, in the region of the transition cartilage. Occurring in the majority of cases in youthful subjects, they lead gradually and steadily with palpable thickening of the bone to curvature and corresponding shortening of the femur. On opening the bone at the curvature a softening cyst of the medulla and cortex is usually found, about the size of a hazelnut, sharply defined, extending into the neck, and of fibrocartilaginous consistence. If not removed, spontaneous fracture may occur ultimately. In rare instances the cystic chondrofibroma reaches the dimensions usually attained only by sarcoma ; in a case of v. Bergmann's the tumor extended from the head to the middle of the femur. In the larger tumors there are, as a rule, several larger or smaller cysts with smooth walls and containing brownish material; they are to be regarded as necrotic masses of the tumor. The surrounding bone is generally very thin, often compressible, and slightly fluctuating, a symptom which facilitates the diagnosis if the tumor is large. Even without this symp- tom the site, gradual growth, the curvature, and shortening are against sarcoma. In the cases known in the literature excision with the chisel and sharp spoon brought about recovery without recurrence. The curvature is overcome by fracturing the bone. Enchondroma. — Enchondroma also occurs in the thigh, and like the above is to be regarded as a growth from a portion of unossified cartilage separated from the bone at the normal point of ossification. 556 DISEASES OF THE THIGH. Chondroma. — Cartilaginous exostoses are etiologically related to the above, developing either as a local manifestation of a general growth of exostoses or occurring alone near the epiphysis, usually the lower. A bursa containing fluid similar to synovial fluid not infrequently develops over the exostoses (exostosis bursata). Their removal is only indicated if they are troublesome. Fibroma. — Fibroma is rare and is usually periosteal in the form of nodules; occasionally they also contain bone, and are then partly attached to the femur, "osteofibroma." Transition forms occur here as elsewhere; it is often difficult to distinguish fibroma from sarcoma. Myxoma. — The periosteal form is a round tumor covered with con- nective tissue; the myelogenous forms are destructive, and form cysts by liquidation of the parts involved. In rare instances the growth has been located simultaneously in the medulla and periosteum. Lipoma. — Lipoma of the shaft belongs to the rarities. Power, Xannoti, Quenu, and Walther have successfully excised congenital peri- osteal lipoma which started near the epiphysis of the lesser trochanter. Inflammatory Osteoid Tumors. — These tumors, which, according to Konig and Honsell, develop along the linea aspira after trauma to the size of a child's head, are benign and can be removed, like the above forms, with the chisel. Sarcoma. — The majority of tumors of the shaft are sarcomata. The myelogenous variety usually starts in the epiphysis, less frequently in the shaft. As the lower epiphysis is the favorite site of the growth, the latter may be mistaken for a joint-inflammation at the outset, but its nature is finally established by aspiration. The joint is usually freely movable. Suspicion of osteosarcoma should always be aroused in an apparent joint-inflammation by the dilatation of the veins of the skin over the joint. This is always caused by compression of the deep ves- sels, and is an early symptom of the growing tumor. The myeloid sarcomata are either round-cell, spindle-cell, or polymorphocellular; the more solid tumors contain giant cells and give. a relatively favorable prognosis. Beginning by destroying the spongiosa, myelosarcoma (osteosarcoma) rapidly distends the bone and forms a large growth covered by a shell of bone; finally the shell is perforated and the sur- rounding structures attacked. An early diagnosis is not infrequently facilitated by spontaneous fracture. Occasionally the tumor is very vascular and may be mistaken for an aneurism; the site and develop- ment give criteria for the proper diagnosis. The periosteal varieties occur commonly in the shaft and are either round-cell, spindle-cell, or polymorphous. The solid spindle-cell sar- coma at first has the appearance of a fibroma and constitutes the transition-form to the latter; it develops more slowly and is generally more benign than the other related varieties, but it is more apt to recur, so that simple excision is usually insufficient. The softer varieties, especially round-cell sarcoma, develop rapidly and are apt to become metastatic. The majority of periosteal sarcomata are spindle-cell or polymorphocellular, and frequently produce bone in the parts adjacent TUMORS OF THE THIGH. 557 t<> thier point of origin; if bone is formed in the rest of the tumor itself, the surgeon is dealing with an osteosarcoma, or, more properly desig- nated, an ossifying sarcoma. Treatment. — Formerly amputation or exarticulation was performed for large myeloid or periosteal sarcoma, resection being regarded as justifiable only for fibrosarcoma or occasionally giant-cell sarcoma. Rapid growth is certainly an indication for high amputation or exarticu- lation; even then the prognosis is bad. On the other hand, the greater range of conservatism has been demonstrated by Mikulicz, who, encouraged by v. Bergmann's and v. Bramann's success in resecting the tibia, performed resection, instead of a more radical operation, for a periosteal spindle-cell sarcoma involving the lower third of the femur. Mikulicz excised S inches of the lower end of the femur, and after being sure that the neoplasm was thoroughly removed sawed off the cartilaginous surface of the tibia and inserted the lower end of the femur in a hole bored in the upper end of the tibia. Wiesinger also recently resected 3 cases successfully. Carcinoma. — Carcinoma is seen in the femur only by metastasis. On the other hand, Goebel recently reported an adenocarcinoma of the femur which showed the structure of a thyroid gland and produced spontaneous fracture. Echinococcus of the femur grows gradually to considerable size and frequently absorbs the bone. Exogenous cysts are often scattered throughout the entire femur, the intervening bone being necrotic. Such extreme cases require radical measures; otherwise the cysts may be curetted out of the medulla and the cavities drained. Tumors of the Soft Parts. In contrast to osseous tumors, the majority of tumors of the soft parts are situated in the upper third of the thigh, being especially common in the inguinal region. In the skin and subcutaneous tissue fibroma, lipoma, fibrolipoma, hemangioma, carcinoma, and sarcoma are rela- tively frequent, the two latter starting from pigment moles; myxoma and enchondroma are less common; osteoma rare. By reason of their superficial position their removal is as simple as the diagnosis. In the inguinal region lymphangioma occurs occasionally in the form of soft tumors even as large as the fist ; they may be felt as a chain of nodules beneath the finger. Echinococcus cysts are very liable to be found here and in the adductors, and, aside from their slow growth, occasionally give the characteristic hydatid thrill. Schrank recently classified the cysts occurring in the groin. Among these are to be men- tioned atheroma, retention-cysts of the sweat-glands, hygroma, lymph- cysts, dermoid cysts. Hydrocele and hematocele are described elsewhere. The inguinal glands may be affected primarily by lymphosarcoma, the tumor becoming adherent to the large vessels and jeopardizing the entire extremity. Tuberculous lymphomata, although rare, are similar to the tuberculous glands in the neck, but fortunately, in contrast, rarely 558 DISEASES OF THE THIGH. involve the vessels. Leukaemic lymphomata give the same symptoms as the well-known swellings in the neck. The inguinal glands may be involved secondarily by sarcoma of the thigh, scrotum, uterus, or carcinoma of the penis, scrotum, or female sexual organs, etc. Secondary sarcoma is not very common; secondary carcinoma of the glands only too often nullifies the effect of the original operation. Recurrence after radical removal of carcinomatous or sar- comatous glands is frequently due, as correctly emphasized by Lennan- der, to the fact that adjacent glands were overlooked; he has therefore proposed complete removal, in one operation, of the glands in the groin and along the obturator vessels and iliac vessels up to the bifurca- tion of the aorta, and claims that there is no danger of hernia. The operation is described on page 560. In the differential diagnosis of tumors in the region of the groin, simple adenitis I bubo) or other inflammations are almost always accom- panied by general symptoms; a gravitation abscess is always accom- panied by the characteristic psoas-contracture; aneurism is almost always of traumatic origin. Retroperitoneal lymph-cysts may appear in the groin as fluctuating tumors the size of a fist and easily be mistaken for a gravitation abscess. (Narath.) Strehl reports a case very similar to Xarath's, which proved to be a serous tuberculous gravitation abscess. In no other part of the body is sarcoma of the muscle so frequent as in the thigh. The growth is almost always situated near the adductors. The fact that it involves the fascia lata at an early period led to the name sarcoma of the fascia lata, whereas, in fact, the tumor develops from the interstitial connective tissue of the adductors. Occasionally the origin is in the vastus interims and externus. Thorough removal of all sus- pected tissues is imperative; if the tumor spreads rapidly, extensive dissection is sometimes necessary; if diffuse, thorough resection by Mikulicz' method or amputation may be required. A myxoma occasionally develops in the muscles, is easily removed, but very often recurs. The nerves of the thigh may be the seat of neurofibroma with a marked tendency to develop suddenly into sarcoma. This malignant tendency is shown especially by congenital multiple neurofibromata of the various nerve-trunks (elephantiasis nervorum of P. v. Bruns); at least, in numerous instances in which a neurosarcoma was apparently solitary, careful examination demonstrated many swellings in various nerve-trunks. Usually when they come under observation the tumors are already large. Occasionally they are sensitive. There may be motor disturbances in the region of the sciatic nerve, or in the muscles supplied by one of its branches, or sensory disturbances. If the tumor has merely flattened the nerve, as is usual, it can be removed without any disturbance of innervation. If resection is necessary, the loss is permanent unless the nerve-stumps can be sutured. As a rule, neuro- mata recur either locally or in other nerve-trunks, and then show increased malignancy by attacking the adjacent tissues. Internal metastasis onlv occurs late in the disease. (Garre, Hartmann.) CHAPTEE XXIX. OPERATIONS ON THE THIGH. LIGATION OF THE FEMORAL ARTERY. The femoral artery runs in a line drawn from a point midway between the anterior-superior spine and the symphysis to the back of the internal condyle. In the upper third of the thigh the artery runs through Scarpa's triangle, which is bounded by Poupart's ligament, the sarto- rius and pectineus, the artery and its vein, to the inner side, being enclosed in the sheath. The vessels lie upon the fascia lata, the con- tinuation of the iliac fascia, and are covered by skin, superficial fascia, and the falciform process of the fascia lata, a triangular layer blending with the inner wall of the sheath of the vessels. In Scarpa's triangle the femoral artery gives off the superficial epigas- tric and the two external pudic arteries directly beneath Poupart's ligament, and about 1\ to 2 inches farther down at the apex of the triangle the large profunda artery, running backward and inward. In the upper third of the thigh the femoral artery lies to the inner side of the sartorius, in the middle third is covered by it, and in the lower third lies along its outer border. On exposing the posterior sheath of the sartorius the vessels are seen beneath, and on dividing the sheath in the middle third of the thigh the long saphenous nerve is found lying upon the vessels. In the lower third the vessels pass through Hunter's canal and enter the popliteal space at a point about 3 inches above the level of the upper border of the patella, the artery at this point lying beneath the vein. The femoral artery can be ligated anywhere in the thigh down to the point where it passes through the adductor tendons. Its pulsation can be felt from Poupart's ligament to the junction of the upper and middle thirds of the thigh. From this point it can be palpated in the groove between the adductor and vastus internus by seizing the thigh with the finger-tips in the groove and pressing against the bone. The preferable sites for ligation are in Scarpa's triangle, in the middle third, and at the junction of the middle and lower thirds. Ligation in Scarpa's Triangle after Larrey (Tig. 360, &).— An incis- ion 2\ inches long is made down to the superficial fascia in the direc- tion of the vessels. The fascia is divided upon a director and the sheath of the vessel opened. The ligature is passed between the artery and vein from within outward. The saphenous vein should be avoided; the crural nerve lies outside of the field. In ligating for a wound or aneurism, the artery is tied above and below and the middle piece ( 559 ) 560 OPERATIONS ON THE THIGH. Fig. 360. excised, all lateral branches from the latter being carefully tied pre- viously. Ligation in the Middle Third, after Bell (Fig. 300, c).— The sartorius is located and the incision made at its inner border. The artery lies in a line drawn from the anterior-superior spine to the internal condyle. After exposing the sheath of the sartorius the muscle is retracted outward, its posterior sheath and the sheath of the vessels opened, meanwhile protecting the long saphenous nerve. Ligation in the Adductor Canal, after Hunter (Fig. 360, d). — The incision is made in the same line as above, and along the outer border of the sartorius, the muscle drawn inward, the sheath opened, and the artery isolated and ligated. Care should be taken to keep in the adductor canal and not seek the artery too deeply. Lennander's Operation to Remove the Inguinal Glands in the Groin and Along the Iliac and Obturator Vessels. — To re- move the glands in the groin and along the iliac and obturator vessels, Lennander makes an incision from the symphysis along Pou- part's ligament to the anterior-superior spine and then along the anterior third or to the middle of the crest of the ilium. From this incision another is made downward on the thigh over the femoral artery. The groin is cleaned out in the usual manner, the deep glands between the superficial and deep femoral vessels also being removed. Pou- part's ligament is then separated from the spine, crest of the pubis, fascia lata, and iliac fascia. The deep epigastric and internal circumflex iliac vessels are double ligated and divided. A few glands usually to be found at the proximal part of these vessels incisions for Hgating the external are sought and removed. The abdominal iliac artery (o) and the femoral ar- musc l es are divided close to the Crest of the terv in Scarpa a triangle (o), in the ... . . . ...... r™ middle third of the thigh (c), and in "lum in the prolonged _ skin incision. 1 he Hunters canal (d). (After v. wini- peritoneum is lifted off in the iliac fossa and warter) iii the adjacent part of the true pelvis. The vas deferens (round ligament), spermatic vessels, hypogastric fold (Liga- menta vesico-umbilicale) or umbilical artery, and the ureter follow the peritoneum. The glands can now be excised en masse in the femoral ring, about the external iliac vessels to the bifurcation of the common iliac artery d — TRANSPLANTATION OF TENDONS. 561 and about the obturator and hypogastric vessels. By lengthening the incision through the skin and muscles along the crest of the ilium, the glands along the common iliac vessels may be removed it' necessary. A drainage-tube wrapped in gauze is inserted up to the iliac vessels in the back of the wound or broughl out in the lumbar region if the incision extends far back. Another drainage-tube is inserted in front of the iliac vessels up to the obturator vessels and brought oul through the skin beneath Poupart's ligament. The latter is sutured carefully back in place, and the abdominal muscles are sutured to the crest of the ilium, leaving a sufficient opening behind for drainage. By the above operation the abdominal wall is injured only in as far as the peritoneum is separated oil' from and sutured again to the bone and fascia. No motor nerves are injured. OPEN STRETCHING OF THE SCIATIC NERVE. Billroth and v. Nussbaum introduced open stretching of the sciatic nerve; it is employed especially for sciatica, paresis and neuralgia of the sciatic due to adhesions, and a few of the spinal-cord affec- tions (tabes dorsalis). Two points are preferable for operation; in the gluteal fold and above the popliteal space. In the gluteal fold a 4\-inch incision is made downward from a point midway between the tuber ischii and the great trochanter and at the level of the former. The gluteus maximus and biceps are exposed and retracted; the sciatic nerve lies beneath. The sciatic artery accompanying it is protected; the nerve is drawn from its sheath and stretched above and below until an appreciable lengthening is obtained. The wound is packed lightly. Above the popliteal space the nerve is found between the biceps and the semimembranosus and tendinosus. The nerve is easily found after incising the skin, subcutaneous fat, and superficial fascia. According to Schede and Xocht, the results are very favorable, among 24 cases 21 recovering, in 1G the improvement being immediate and permanent. Quenu reports a case of sciatica due to numerous varicosities and cured by their removal. Delageniere found the nerve enclosed by a thick network of small tortuous veins, by tearing which complete recovery was effected. Various other nerves have been stretched or resected in the thigh. Lauenstein excised part of the obturator nerve for a contraction of the adductors of central origin. Haenlein removed part of the genito- crural for neuralgia. The same operations have been performed on the crural. TRANSPLANTATION OF TENDONS. Recently the tendons have been transplanted repeatedly for par- alysis of single muscles, especially in infantile paralysis. Cases are reported of suture of the sartorius to the tendon of the paralyzed quadri- Vol. III.— 36 562 OPERATIONS ON THE THIGH. ceps; the result was fairly good, after the sartorius had been strength- ened by massage, electricity, and gymnastics. This after-treatment is very important. Lange's method of using the flexors to replace the extensors has proved valuable. Lange divided the biceps and semi- membranosus at their insertions, brought the tendons forward, united them above the patella and connected them with the spine of the tibia by a strong silk thread carried over the patella. It often suffices to suture the flexor tendons to the patella. (F. Krause.) AMPUTATION OF THE THIGH. On account of the thick muscular covering at the middle of the thigh amputation by any of the various methods gives an equally good cover- ing over the stump. In the lower part of the thigh the oval or flap incision is better than the circular incision on account of the position of the cicatrix ; in the upper part of the thigh the oval incision is best. According to the level, surgeons distinguish high, intermediate, supra- condyloid, and intracondyloid amputation. In high amputation the handle of the racket or oval incision (Fig. 343), on the outer side of the thigh, is carried down to the bone and permits the same to be exposed subperiosteal^ to the point of removal. The femoral artery and vein, profunda artery, comes ischiadicse, and branches of the circumflex are to be ligated. The sciatic and crural and other large nerves are drawn out and cut off high up. In the middle third, to the circular incision are added two lateral longitudinal incisions to aid in dissecting back the flaps if the muscles are thick; or a large anterior and a small posterior flap are made and the muscles divided straight across. In thin subjects it is advisable to form lateral flaps from the sides giving the thickest muscles. The out- ward rotation of the stump occurring occasionally after operation is due to contraction of the outward rotators, (v. Winiwarter.) If the stump is short, it may be drawn up to a right angle by the flexors. To strengthen the end of the stump, Bier recommends suturing a periosteal flap over it. In amputating above the condyles an oblique or flap incision is made on the front and inner aspect, as the adductors draw the thigh forward and inward so that an anterior incision would bring the scar too much under the inner edge of the bone. Spence's large anterior and small posterior flap-method, modified by Farabeuf, is much used. In this also the anterior flap is made preferably a little to the inner side. Gritti's osteoplastic amputation gives an excellent stump: An anterior curved incision is made from the condyles to the spine of the tibia; the liga- mentum patellar is divided at its insertion and the flap containing the patella is dissected back. A posterior flap is made of the same length. The muscles are divided close above the condyles and the femur sawed off | inch above the upper margin of the cartilage. The patella is then sawed through on the flat, the articular half removed, and the anterior AMPUTATION OF THE THIGH. 563 portion together with the flap of the soft parts turned up and back upon the surface of the femur, the edge of the patella being sutured to the periosteum of the latter and to the deep fascia. [ntracondyloid amputation was uamed after Carden and Buchanan. In children Buchanan simply removed the lower end of the femur in the epiphyseal line. Carden sawed off the condyles in an antero- posterior curve and obtained an excellent rounded stump; he made an oblique incision beginning on the posterior surface at the level of the epicondyles and curving downward and then forward to the spine of the tibia. The skin and fascia are dissected back to above the patella and the quadriceps divided down to the synovial sac; the latter is exposed and dissected from the bone to below the epicondyle, without opening the joint. A curved incision, convex downward, is then made above the margin of the cartilage, passing backward below the epicondyles, dividing the attachments of the lateral ligaments and ending trans- Fig. 361. Fig. 362. Ssabanejeff's osteoplastic operation. versely behind above the attachment of the synovialis above the con- dyles. The lower epiphysis of the femur is sawed off in an antero- posterior curve in this line to form a rounded stump and the soft parts divided behind. Recently Ssabanejeff proposed an osteoplastic intracondyloid ampu- tation preserving part of the front of the tibia in the anterior skin-flap. (Figs. 361 and 362.) After incising and dissecting back the skin and fascia a bone-flap is sawed from the front of the tibia, as in the diagram, and turned up against the surface of the femur. The attachments of the sartorius, gracilis, and biceps are thus saved and the end of the stump is covered with skin and bone which are accustomed to pressure. Djelitzyn modified this method by sawing the femur and tibia off at an angle of 45 degrees to the long axis, including the head of the fibula and the insertion of the biceps in the anterior flap, opening the knee-joint from below after sawing off the tibia and fibula, and then forming the posterior 564 OPERATIONS ON THE THIGH. flap and ligating the vessels. Jacobson and Abrashanow further modi- fied the method by preserving the flexors and their insertions. Jacobson makes a racket incision beginning in the popliteal space, running downward and forward to end f to 1^ inches below the spine of the tibia. The popliteal artery is ligated, the soft parts divided, the biceps, sartorius, gracilis, semimembranosus, and semitendinosus being lifted off with the periosteum from the bone. The gastrocnemius and plantaris are divided, the joint opened from behind, dislocated forward, the bone-flap sawed off as in Fig. 361, the sawn surfaces apposed, the biceps tendon sutured to the outer margin of the tibial segment, and the other tendons sutured to the stumps of the gastrocnemius and plan- taris. The wound is sutured longitudinally. Abrashanow recom- mends a large posterior flap including skin, muscles, and periosteum if the flap cannot be made from the anterior surface of the leg. In the small anterior flap are included the patella and insertion of the rectus, analogous to Gritti's method. The results of Ssabanejeff's method have thus far been very good, the patient kneeling in the true sense of the word upon the tuberosities of the tibia. Hilgenheimer recommends the method if sufficient flap material is present, otherwise Gritti's opera- tion. If this is not possible, Carden's transcondyloid method. Hoftmann's prothesis is serviceable to replace the limbafter amputating high up or at the hip. The artificial limbs, as first constructed by Hoft- mann for an eighteen-year-old patient with total congenital defect of both, limbs, were made so that the line of gravity fell in front of the knee-joint, the false limb thus becoming rigid at each step as the body- weight was thrown upon it. The limbs, hinged to a pelvic brace, swung forward alternately as the patient lifted one side of the pelvis and then the other, so that the gait was hardly noticeable. The arti- ficial limbs of Hoch and Hunzinger in Cologne, and of Eschbaum in Bonn, made according to the directions of Busch and Trendelenburg, are also very good. For the stump after amputation lower down one of the best artificial limbs is that of Pfister, of Berlin, highly recommended by Ivarpinski and Gollmer. Very much the same pattern is constructed, with slight modifications, by Erfurth and Geffers; Middendorf, of Minister, in Westphalia, has devised a very useful leather sheath appartus. Nyrop constructed a wooden leg with a flexible, light and durable leather foot. In America the artificial limbs of Marks and Hudson are commonly worn. At the Surgical Congress in 1902 Engels, of Hamburg, demon- strated a very useful artificial limb with a flexible knee-joint. INJURIES AND DISEASES OF THE KNEE AND LEG. By Oberakzt Dr. P. REICHEL. INJURIES AND DISEASES OF THE KNEE. CHAPTER XXX. INJURIES OF THE KNEE. CONTUSION AND SPRAIN OF THE KNEE. Contusion of the knee, usually due to a direct fall or blow, although a very frequent injury and commonly combined with abrasion of the skin, is usually without further significance and heals without medical treatment. Severe contusion sometimes causes extensive extravasation of blood in the loose subcutaneous tissue with ecchymosis and diffuse swelling of the soft parts; usually the blood is rapidly and entirely absorbed. An effusion of blood in one of the periarticular bursa 3 , most frequently one of the prepatellar, is absorbed more slowly. The characteristic situation in front of the patella, the hemispherical form, and fluctuation of the tumor make the diagnosis easy. The tumor is less sharply defined, however, on account of the extravasation in the subcutaneous tissue than in chronic bursitis. As in the joint, the blood separates into clot and serum. If the bursa ruptures spontaneously or from the action of the trauma or the pressure of a bandage, the blood is poured out into the subcutis and is absorbed more quickly. Rosenberg has seen several cases of "riders' pain of the patella," due to the pressure of tight riding-breeches, in which there was severe or almost unendurable pain produced by the slightest pressure against the inner border of the patella. It usually occurred in young subjects other- wise healthy- The objective finding was negative. Rest, removal of the pressure, and cold compresses alleviated the pain; recovery required several weeks. The wearing of looser breeches is the first requisite to prevent recurrence. Contusion acquires greater significance if the joint is involved. In this case the capsule and ligaments are often sprained or torn slightly. Hemorrhage then takes place into the joint, primary ha?marthrosis, and later there is increased secretion of synovia, namely, a secondary serous (565 ) 566 INJURIES OF THE KNEE. synovitis. The amount of hemorrhage usually corresponds to the severity of the trauma; in rare instances slight injury is followed rapidly by pro- fuse hemorrhage distending the capsule almost to bursting. Clinical experience has shewn that the blood may remain fluid for a long time — even three weeks — although coagulation commonly occurs after the first few days. The time at which coagulation occurs depends apparently not so much upon the duration of the exudation as upon the nature and severity of the injury, beginning early in cases of extensive laceration of the capsule, especially if associated with fracture of the patella or of the joint-surfaces, and starting at the point of injury; so the blood-clot is usually attached firmly to the tear in the capsule or at the point of fracture of the patella or of the surfaces of the joint. Diagnosis. — In simple sprains the skin is at first unchanged over the injured joint, later becoming more or less ecchymotic. Ecchymosis at the onset denotes contusion or extensive laceration of the capsule. Ecchymosis may occur later from spontaneous rupture of the distended capsule, most frequently in the upper recess, and reach to the groin. This aids and hastens the resorption of the blood, and is therefore per se not so undesirable. Hremarthrosis is characterized by rapid distention of the capsule after the injury; the longitudinal furrows at the sides of the patella are oblit- erated, the line of the capsule becomes more pronounced, especially above the patella. The patella is lifted from the condyles, as in synovitis, and the patellar click — "dancing of the patella" — can be elicited if the tension is not too great. According to the absence or presence of coagu- lation, the swelling fluctuates or is more or less doughy and gives the so-called "snow-ball crunching" on pressure. If the soft parts about the joint are severely contused, the articular swelling is more or less obscured. Motion is more or less painful and limited. The knee is held slightly flexed. The difficulty of diagnosis lies not so much in demonstrating a joint injury as in excluding complications, separation of small fragments of cartilage or bone, avulsion or dislocation of a meniscus, all of which occur more frequently than the inexperienced suppose. Careful palpa- tion and the use of the ;r-ray are the only protection against the occa- sionally serious and protracted functional disturbance caused by such undiagnosed complications. Prognosis. — Simple contusion not involving the joint usually yields rapidly with moderate elevation, application of wet dressings, and massage. Abrasions of the skin or laceration extending into the subcutis or the proximity of a furuncle are liable to cause infection of the bruised tissues and lead to extensive phlegmon about the knee and along the thigh, and may threaten the limb or life of the patient. There is every reason therefore to treat all such slight wounds accompanying contusion of the knee according to all the rules of asepsis. Occasionally contusion of the bursa causes a serous exudation in the sac; repeated slight injury may give rise to a chronic bursitis. Contusion or sprain of the knee-joint usually recovers fully if properly treated. Improper COXTUSlOy AND SPRAIN OF THE KNEE. 557 treatment, insufficient protection at the outset, is not infrequently the reason for the transition of a primary acute serous synovitis into a chronic hydrops with relaxation of the capsule, loose joint, and severe functional impairment. Partial stiffness, especially in elderly individuals, may follow the injury; usually it is due to protracted immobilization. In a few instances the injury has been followed by a deforming inflammation of the joint. The influence of predisposition is still an open question. It is certain that such a predisposition, especially hereditary, favors the development of tuberculosis in the contused or sprained joint, hut more frequently in children than in adults. Suppuration of the joint following a simple Mil 'cutaneous injury is very rare. Treatment. — In mild cases, rest for a few days and compression are sufficient. Severe injuries with evident effusion are preferably im- mobilized for a few days in a strip splint. Further measures depend chiefly upon the amount of articular hemorrhage; its rapid and complete removal is important for the functional restoration of the joint. The longer a blood-clot remains in a joint the more it favors chronic serous exudation or prolonged stiffness. Resorption is aided by pressure, moisture, and warmth. The joint is wrapped in a wet dressing of 2 per cent, aluminum acetate covered with rubber tissue or wax paper, and bandaged in a Yolkmann splint. The elastic compression of a rubber bandage acts more energeticallv; the limb should be supported in a tin gutter-splint, with a cotton pad under the knee to prevent pressure upon the popliteal vessels, and the elastic bandage applied over the knee and splint. Excessive compression is therein- impossible. The bandage should not be applied too tightly, and should be changed daily, at each change the knee and muscles of the thigh being massaged carefully but thoroughly for five to ten minutes and slight movement of the knee carried out passively. If the bandage is too tight the pain becomes unendurable; if properly applied the con- tinuous elastic compression causes the effusion of blood to be resorbed with striking rapidity. Moderate effusions are absorbed in this man- ner in from eight to ten days. The splint can often be left off after a few days, but the joint should be wrapped in flannel for some time. The question as to how long to immobilize and how energeticallv to carry out the movements will depend upon the sensitiveness of the joint and the amount of effusion. In general, immobilization should not be continued more than six to ten days. Massage and early motion mate- rially aid the resorption of blood and serum, especially in young other- wise healthy patients. The joint should not be encumbered by walking too early. If the contusion or sprain of the joint is at all severe, the patient should not be about until several days after the effusion has disappeared entirely and remains absent in spite of active and energetic movement of the knee in bed. A bandage or elastic knee-cap should be worn for some time. The effusion often returns on walking; if moderate, massage and exercise are not interrupted; it soon disappears. If it increases or inflammatory symptoms appear, rest and pressure should be enforced for a short time. 568 INJURIES OF THE KNEE. Large effusions or large hemorrhages in the joint which do not yield to treatment should be aspirated early, and if necessary a small incision made and sutured again. Statistics prove that such interference gives a shorter course of recovery and a more complete result. Bondesen gives the average period of recovery with aspiration as 22.4 days, without aspiration 38 days; Lubbe, in 32 cases aspirated, an average of 22.5 days, and in 22 not aspirated — although these were mostly mild cases — 34.6 days. Bondesen states that recovery was complete in 86 per cent, of the aspirated cases and in only 63 per cent, of those not aspirated. For aspiration one uses a trocar and canula or needle, sterilized by boiling, sufficiently large to remove any clots or fibrin. If the blood does not flow freely the joint is filled with sterilized salt solution or 0.5 to 1 per cent, carbolic or 3 per cent, boric-acid solution, the clots broken up by careful massage, and removed by thorough irrigation. The puncture wound is closed with iodoform-collodion or sutured, and an aseptic dressing applied with slight pressure and left on till the wound heals — about 6 to 8 days. During this time the limb is immobilized in a tin or wire gutter-splint. The rest of the treatment is as above. The strictest asepsis is unconditional. If it cannot be carried out, it is better to confine the treatment to compression and early massage, as aspiration is a procedure more for the hospital than the houses of poor patients. Aspiration or incision is usually performed on the second or third day after the injury. Recovery requires several weeks, and in otherwise healthy and not too aged patients results not only in the return of com- plete mobility and strength of the joint, but also in a permanent cure without the danger of recurrence. WOUNDS IN AND ABOUT THE KNEE-JOINT. The common abrasions and superficial lacerations of the skin from falls or blows upon the knee, and the less frequent stab-, incised, and puncture-wounds in front of the joint from sharp or pointed instruments, have little significance as long as the joint is not involved. Such injuries on the posterior surface endanger the flexor tendons, tibial and peroneal nerve, popliteal artery, and short saphenous vein. All these injuries are rare, and their diagnosis made simply by observing the situation of the wound and the functional disturbance. Their treatment is on general principles. Any necessary suture of tendons or nerves, or ligation of bleeding vessels, is facilitated by applying the Esmarch. Wounds of the joint or about the joint have acquired especial signifi- cance. To a certain extent the puncture-wounds produced by falling upon a nail or by the thrust of an awl are typical; so also the incised wound from a misstroke of an axe. Wounds made by dagger-thrusts, glass, or bursting machinery, etc., are less frequent. Involvement of the joint is manifested by exposure of the cartilage, discharge of syno- via, or by hsemarthrosis, although slight wounds of the joint are not always followed by an effusion of blood. If the wound is not large, WOUNDS IN AND ABOUT Till-: KNEE JOINT. 569 these symptoms may be absent, as the skin and capsule are easily shifted upon each other and only coincide in certain positions. It' the knee is wounded while flexed, the opening into the joint is completely covered in extension, and the reverse. This is significant in regard to primary infection, secondary infection, and recovery, as under certain circum- stances secondary infection may not involve the joint. In many instances the entrance of air into the joint during motion distends the capsule and gives a tympanitic percussion note easily distinguishing the condition from the similar contour produced by acute ha j marthrosis. The air is rapidly absorbed. In the absence of other complications the significance of penetrating wounds of the joint depends upon infection. Foreign bodies — for example, a needle — often give rise to active disturbance by wander- ing. Their demonstration and removal are facilitated by the .r-ray. Infection may cause mild serous synovitis or the severest kind of panarthritis. To probe or finger the wound merely to determine whether the joint is opened or not is counterindicated as being purpose- less even under antiseptic precautions; without such precautions it is thoroughly reprehensible. In doubtful cases the wound should be treated as a joint-wound. If the entrance of a foreign body into the joint is suspected, probing is justifiable after thorough disinfection; but even then it is better to enlarge the wound under application of the Esmarch. If the wound is clean, with no signs of inflammation, it should be sutured without drainage, all torn tissues being excised. If infection is apprehended, the wound is packed with iodoform gauze. Small punc- ture-wounds, slightly swollen and tender, but without fever, such as are caused by a needle or nail, often yield to rest, antiseptic wet dressings, and slight pressure. If there are signs of an infectious synovitis, the treatment is the same as that given later for acute inflammations of the knee-joint. Gunshot-wounds of the joint require special consideration. It is easy to understand how grazing shots can injure the capsule alone, and how those entering at right angles to the limb can perforate the upper recess of the capsule or the space below the patella between the ligament and the tuberosities without injuring the joint-surfaces. Simon was the first to show by experiments on the cadaver that with the knee flexed between 130 and 170 degrees a bullet could perforate the joint from before backward without touching the bones, and thus explained the favorable course of many shot-wounds of the knee with entrance in front and exit behind which Stromeyer regarded as contour- shots on account of their occasionally favorable course. In the large majority of cases of gunshot-wounds of the knee the bone is injured more or less severely. Small-calibre bullets at long range frequently produce furrowed, or clean perforating wounds, as seen by Kiittner in the South-African War, whereas at moderate range splintering was the rule in the compact upper end of the tibia. Shots at close range cause extensive shattering of one or both condyles of the femur or of the tuberosities of the tibia, often with considerable splin- 570 INJURIES OF THE KNEE. tering or Assuring of the shaft. So it is seen that they still produce severe injuries, although the prognosis is so improved by modern antisepsis that the statistics of former wars no longer apply. Kiittner reports hemorrhage in the joint as constant in recent gunshot- wounds of the knee even with mere perforation of the capsule. In one instance pulsation was transmitted directly to the hsemarthrosis from an aneurism of the popliteal artery communicating with the knee-joint. Formerly suppuration was the rule, so that in all severe gunshot-wounds of the knee primary amputation was performed by many surgeons as the best mode of treatment. It was after the war of 1866 that v. Langenbeck first called attention to the favorable results of conservative measures for such gunshot-wounds. Still, the credit is due to v. Berg- raann of having demonstrated not only the qualifications of conserva- tive treatment as aided by antisepsis, but also its superiority as based upOn his experience in the Russian-Turkish War. Of 15 gunshot fractures of the knee-joint cleansed superficially with carbolic acid, wrapped in 10 per cent, salicylated cotton, and immobilized in a plaster-splint, 14 recovered, mostly without suppuration. By means of primary antisepsis Reyher obtained a movable joint in 15 of 18 gunshot-wounds of the knee. The results of conservative treatment of small-calibre wounds of the knee in the South-African War were surprisingly favorable. (Kiittner, MacCormac.) Such results are conditional upon the wound being touched only by fingers, instruments, and gauze which are carefully sterilized, v. Berg- mann recommends that on the battlefield the wound should not be dis- turbed, but be covered with iodoform or iodoform gauze, a padded splint applied, and the patient transferred as soon as possible to the nearest field hospital. In the absence of signs of infection the treatment here should also be conservative and expectant. Suppuration calls for incision or resection and the removal of bone splinters and foreign bodies. Exten- sive laceration of the bone and soft parts caused by bomb-shell frag- ments or shots at close range requires primary or secondary amputation. INJURIES OF THE POPLITEAL VESSELS. As the large popliteal vessels are protected by their deep situation, injuries of the same are seen chiefly as complications of other injuries, namely, crushing of the knee in runover or railroad accidents, less frequently puncture- or gunshot-wounds. Subcutaneously the vessels are injured by fracture splinters or are ruptured in complete backward dislocation of the tibia. If ruptured or crushed, the involution of the intima may prevent hemorrhage. Usually lesions of the vessels are followed by very severe hemorrhage; if the injury is subcutaneous, the extravasation may compress the veins, cause thrombosis, and endanger the limb if not checked. Exceptionally severe contusion produces rupture of the inner coats, the adventitia remaining intact, and leads to the formation of an aneurism, less frequently thrombosis. In v. Bruns' FHACTriiKS OF THE ('OXI)YLFS OF TJIF FFMUR. 571 clinic a case of contusion of the knee without injury of the skin was seen, which was followed by gangrene of the leg; the popliteal artery was found to be thrombosed and both inner coats ruptured. Aneurism follows small-calibre gunshot-wounds of the popliteal artery with striking frequency. Unless exceptional circumstances present a strict counterindication the injured vessel should he exposed and double ligated if the existence of other injuries does not demand amputation at the knee-joint or higher. Single ligation of the femoral artery above the injury has been abandoned as being uncertain. The few reports of suture of the vessel for partial division of the artery or vein have been favorable. A double row of continuous sutures is made with fine silk or linen thread and a small curved needle; the first row includes the entire thickness of the wall, the second the adventitia. Lateral ligation or suture of the vessel is only advisable if the patient can be kept under constant observation. FRACTURES OF THE CONDYLES OF THE FEMUR AND OF THE TUBEROSITIES OF THE TIBIA. Fractures of the Condyles of the Femur. — Fractures of the condyles are very similar to the articular fractures of the lower end of the humerus. Transverse supracondyloid fractures and trau- matic separation of the epiphysis do not involve the joint primarily. The typical forms are the oblique fractures of one or both condyles, and the T- or Y-fractures, in which both condyles are separated from the shaft and from each other. (Fig. 363.) The fragments of the con- dyles are usually large ; less frequently small pieces are broken off. If both condyles are broken, the lines diverge upward to end above the epicoiK Ivies. Aside from these typical forms irregular and multiple fractures occur. The cause is severe violence, direct or indi- rect, a fall or blow upon the knee or by falling upon the feet from a height. Madelung be- lieved that T- and Y-fractures were produced by a wedge action of the patella, but Marcuse pro- duced these fractures on the cadaver after re- moving the patella. Probably Gosselin's former theory is correct, that the shaft is forced between the condyles and wedges them apart. Forced abduction or adduction of the leg tears off the lateral ligaments from the bone, but does not produce an oblique fracture of the condyle. The intra-articular fractures are rapidly followed by hemorrhage into the joint which conceals the otherwise easily palpable contour of the T-fracture of the condyles of the femur due to a fall upon the knee. (v. Bruns.) 572 INJURIES OF THE KNEE. bones. The functional loss, false motion, bony crepitus, and typical displacement, however, are usually so distinct that the line of fracture can be rapidly traced out. The condyles are always apt to be dis- placed upward, fracture of the outer condyle giving a valgus position - of the inner a varus position. T- and Y-fractures increase the width ot the condyles and shorten the femur. Passively the leg can be abducted or adducted. The fractured condyles can be shifted upon the shaft. Prognosis. — The prognosis is that of all intra-articular fractures. Partial stiffness may persist, extension and flexion be limited, the use of the limb weak and uncertain, and combined with more or less pain and a tendency to recurring chronic serous synovitis. Slight dis- placement of the fragments is hardly avoidable as exact coaptation is hindered by the swelling and later correction is impossible. The resulting unevenness of the cartilaginous surface of the joint disturbs the normal motion of the tibia upon the femur. Arthritis deformans may follow. Complete restoration of function is rare. Treatment. — Aside from correcting the valgus or varus position, the blood in the joint should be removed as rapidly as possible by the meas- ures previously mentioned, namely, daily renewal of wet compresses or a rubber bandage and immobilization in a long well-padded Volkmarm splint; also early massage and if necessary aspiration with or without lavage of the joint. If the swelling subsides in six or eight days, the limb is straightened as much as possible and immobilized in a circular or posterior plaster-splint if only one condyle is broken. The splint is removed at the latest in two weeks, and gentle passive motion carried out at the joint with massage of the joint and muscles of the leg and thigh. The limb is then immobilized again for fourteen days, after which the plaster-splint is replaced by a strip splint. It is even better to apply the strip splint earlier, at the end of the second or third week, and begin massage and motion as soon as possible. If the condyle shows little or no tendency to displacement, immobilization upon a simple strip splint may be sufficient. The extension treatment is preferable for Y-fracture, as otherwise it is difficult to prevent the upward displacement of the condyles and the resulting shortening. It may be applied on the first day, the adhesive strips reaching to the middle of the thigh; it does not prevent any necessary treatment of the hoemarthrosis. Extension is removed as soon as the callus holds the fragments and a plaster-splint then applied. On account of the greater tendency of the fragments to displacement movements should be delayed longer than in the case of oblique fracture of one condyle. Fractures of the Tuberosities of the Tibia. — The cause is the same as that of fractures of the condyles of the femur. Often there is merely a fissure in the head of the tibia; or avulsion of smaller or larger pieces of the marginal cartilage without displacement; or there may be an oblique fracture of a large part of or the whole of one tuberosity with displacement and a corresponding varus or valgus position; or the line of fracture may run transversely near the joint-surface, the upper FRACTURE OF THE PATELLA. 573 corn- It is Fig. 364. Fragment being intact or, more commonly, splintered. If the fragment is large, it is liable to become flexed while the shaft remains extended. The shaft has repeatedly been found wedged in the cleft spongiosa of the head. (Fig. 364.) A typical form, typical etiologically and anatomically, is the pression fracture of the head of the tibia described by Wagner. caused by falling upon the feet from a height, and is therefore often bilateral or accom- panied by simultaneous injury of the other limb. The condyles of the femur drive the menisci into the spongiosa of the tibia and may wedge the tuberosities apart. Usually the inner tuberosity is compressed more than the outer, although either may be injured singly. In all these fractures there is hemorrhage in the joint, usually profuse, the swelling pre- venting accurate palpation. The diagnosis is therefore often difficult and can only be made with probability, as the displacement may be slight and the patient able to walk, the only symptom being marked local ten- derness. Usually, however, there is distinct false motion, crepitus, characteristic displacement, varus or valgus position, h to £ inch shortening, and pronounced broadening of the tuberosities. Treatment. — The treatment is the same as that of fracture of the condyles of the femur, rapid removal of the blood in the joint, extension for fourteen days, then a plaster-splint reaching from the toes to the groin and motion and massage as early as possible, at the latest in the sixth w r eek. When up and about, a removable supporting splint of plaster or silicate should be worn for a few weeks; not a few patients require such a splint for many weeks. Fracture of the head of the tibia with impaction of the shaft in the epiphysis. (Hoffa.) FRACTURE OF THE PATELLA. Fracture of the patella is most frequent between the thirtieth and fiftieth year, is rare before the twentieth year, and is almost never seen in children under ten. It is much more common in men than in women. (88 per cent., Rossi.) It represents 1.4 per cent, of all bone fractures. (v. Brims, Rossi.) One distinguishes simple (subcutaneous) and com- pound, transverse, longitudinal, oblique, and comminuted fractures. By far the greater number of simple fractures are transverse. (80 per cent., Rossi.) The fracture-line either divides the bone into two equal frag- ments, an upper and a lower, or, more commonly, lies below, or rarely bove, the middle line. (Fig. 3G5.) Often the lower end, not covered with cartilage, is torn off alone, rarely the upper tip. Malgaigne and Bahr 574 INJURIES OF THE KXEE. have demonstrated that the line is usually oblique from above and without, downward and inward, rarely the reverse. Cases of twofold or even threefold transverse fracture are reported, the latter resulting almost exclusively from later refracture. In direct, and especially in compound fractures, the lower fragment is occasionally divided longitudinally into two parts, thus giving a T- or Y-fracture. Comminution is a frequent result of direct violence. Longi- tudinal fracture is very rare. The frequency of incomplete fractures, namely, fissures not involving the cartilage, is not known definitely, as the diagnosis is seldom possible without the .r-ray. Fracture of the patella usually signifies an accompanying injury of the joint. Associated Fig. 365. Recent transverse fracture of the patella. (▼. Brans.) injuries of the soft parts over and at the sides of the patella are very significant. The fracture may be purely subaponeurotic without dis- placement or typical symptoms, and only be discovered with the x-ray. Wegner recently reported 3 cases, 2 from direct, 1 from indirect violence. In the greater majority of cases the dense fascia covering the patella is torn, and with it part of the capsule, the reinforcing tendinous fibres of the vastus interims on the inner side and the prolongation of the fascia lata on the outer side, the so-called "reserve" extensor apparatus of the lea is thus partially or completely severed. The prepatellar burst is often contused, and may contain blood or its posterior wall may be torn. FRACTURE OF THE PATELLA. 575 Macewen's and Konig's clinical observations and Holla's experiments on the cadaver have shown thai the tear in the aponeurosis does nol always correspond to the fracture-line, but more frequently lies above or below it, the tab being very apt to get between the fragments and prevent bony union. Cause. — The cause is usually a fall, less frequently a blow from a hoof or a stone, or a gunshot-wound, etc. All compound fractures are unquestionably direct. Many views still exist at the present time as to how far simple transverse fractures are referable to direct or indirect violence. Many patients give reliable testimony that the fracture and the pain were felt at the moment of sudden contraction of the extensors to prevent a fall backward. Sanson affirmed that the patella was bent while' the knee was flexed, as one would break a stick over the knee. Bahr, among others, demonstrated later, however, that in the flexed position the surface of the patella was applied closely to the femur, and that the contraction of the quadriceps merely increased the contact. The statistics of Bahr and Rossi show that the effect of muscular traction has been overestimated, Rossi stating that the infrequency of rupture of the quadriceps tendon or the ligamentum patella? pointed rather to a pathological condition of the patella. At any rate, the fracture is commonly the result of a direct fall upon the knee, the fracture being due to the fall and not the reverse. The view that in falling upon the knee the blow is always received at the spine of the tibia and not upon the patella is not correct, as can be demonstrated by placing the hand under the knee; it applies only when the foot is extended. When the foot is flexed the lower end of the patella strikes the ground, and the lower portion, projecting beyond the condyles, is broken off transversely. When the patella strikes a sharp edge it may be broken higher up, transversely or obliquely. Symptoms. — The patient usually hears and feels the snap as the bone breaks and is then unable to extend the limb. If the fracture is incom- plete or purely subaponeurotic, and the lateral portions of the capsule are intact, the patient may be able to walk or even to climb stairs. The fragments may be in contact, or be separated by a slight groove, or lie ■j to I- inch apart with an appreciable transverse groove between them. They are usually separated widely if there is very much hemorrhage into the joint. The fracture may be concealed by hemorrhage in the prepatellar bursa. In the large majority of cases of transverse fracture the displacement is marked. As a rule, the .r-ray is necessary to diag- nose the rare incomplete and purely subaponeurotic fractures. Crepitus is absent till the fragments can be pressed together. Hemorrhage into the joint is constant with fracture of the patella; if very profuse, it may rupture the upper recess of the capsule, as noted by Riedel. The blood may spread out beneath the quadriceps and under the skin of the thigh. Prognosis. — Apart from the age of the patient and complications, especially the extent of the tear in the capsule, the prognosis depends upon the treatment. Simple fracture without displacement of the frag- ments is usually followed by bony union and gradual restoration of 576 INJURIES OF THE KNEE. function. The greater the ateral tear of the capsule and of the reserve extensors, the greater the loss of active extension ; although many patients are able to go about with or without a cane, others are obliged to drag the limb. There is the further danger of partial or complete stiffness. So with large tears of the capsule the prognosis is always doubtful, and is at least less favorable than the prognosis of most fractures of the shaft of the bones. Treatment. — Non-union or inadequate union and the resulting inability to extend the leg are the most frequent causes of partial recovery. That fibrous union and the absence of bony union are not due to insufficient nourishment of the fragments is proved, aside from the cases in which bonv union occurs, by the results of v. Yolkmann's transverse division of the patella in resecting the joint. The fault lies in improper coapta- tion of the fragments, and this in turn is due to three factors: 1. Con- traction of the extensors. 2. Intra-articular hemorrhage. 3. Interpo- sition of periosteal tabs, as cited by Maeewen, Konig, and Hoffa. The rational treatment therefore consists in overcoming these three hin- drances. Interposition can be recognized and overcome only by operation, but as it is present in only a part of the cases a large field is still left for conservative treatment. Hemorrhage if not already present may be prevented somewhat by compression with wet bandages and by elevation in a Volkmann splint to relax the extensors. If the joint is much distended, an elastic bandage should be applied or the joint aspirated, as done by Schede. The coaptation and fixation of the fragments then follow. Only the more practical methods will be mentioned. The simplest is by means of an adhesive-plaster bandage, the upper and lower transverse strips being applied tightly above and below the fragments while they are held in position, the intervening strips exerting uniform pressure over the patella. Rubber plates may be moulded over the fragments to give a better hold. The plates are softened in hot water, applied, and bandaged in place. As the application of a plaster-splint is liable to be followed by atrophy of the quadriceps and stiffness of the joint, it is better to use a long strip splint and massage the limb daily, v. Bra- mann obtains continuous elastic pressure against the fragments by means of a rubber band stretched between two circular adhesive plaster strips, applied above and below the patella. Bardenheuer and Lichten- auer recommend weight- extension, the same as for fracture of the femur, as a rule after aspirating the blood, if for any reason open suture is not possible or necessary. Thirty to forty pounds are applied to "tire out" and relax the extensors and thereby overcome the traction upon the fragments; the extension is continued for four to six weeks, till union occurs. Of the older direct methods, Malgaigne's clamp method is merely of historic interest. Trelat's modification of this, of fastening the hooks to rubber plates modelled to the fragments, has no advantage over the simple bandage described above. The introduction of antisepsis made FRA CT URE OF THE I'M 'E L LA. 577 it possible to suture the hones with less apprehension; that the ideal is not always attained by suture, however, is indicated by the number of new met hods extant and the constant strife over subcutaneous and open suture. Subcutaneous suture of the tendons, proposed by v.Volkmann in 1868, represents the forerunner of direct suture of the bone. A cord was passed transversely through the ligamentum patellae and another through the quadriceps tendon close to the patella and the ends tied together over gauze. Kocher passed a silver wire on a curved needle underneath the patella from above and out below, and tied the ends together over a gauze pad; at first he made two short incisions through the skin to pre- vent necrosis; later he made a long incision and buried the suture. The fixation was not certain and the wire in the joint irritated the carti- lage. Ceci sutured the bone subcutaneously by boring through the fragments with an awl having an eyelet: beginning at the lower inner angle he bored through both fragments to the upper outer angle of the patella, threaded the eye with silver wire and withdrew it ; from the Fig. 3G6. lower outer angle the awl was passed along the lower edge of the patella to the first hole and the wire drawn through ; from the upper inner angle the awl was passed through both fragments to the last hole, threaded and with- drawn ; the two ends were then united through the quadriceps ten- don at the upper outer angle, twisted tightly, cut off, and inverted into the hole into the bone ; the four small skin punctures healed quickly. Heusner's method, simi- lar to Butcher's older method, of passing the silver w r ire subcutane- ously around the patella in the tendons and periosteum, differs from Ceci's method in thus avoid- ing the joint and in encircling the patella rather than passing in a cross through it. Barker passed a curved awl with an eyelet into the joint below the patella and out above the upper fragment, threaded it with silver wire and withdrew it; from the same point the needle was passed subcutaneously over the patella, out through the second hole, threaded with the other end of the wire, withdrawn, and the wire tight- ened, twisted, cut off, and buried. The disadvantages of every subcu- taneous method are that the interposition of the periosteum and lateral tears are disregarded, and that the joint may be opened. Vol. Ill— 37 Fracture of the patella united by suturing the fragments, (v. Bruns.) 578 INJURIES OF THE KNEE. Open suture of the patella under antiseptic conditions was first per- formed by Lister, in 1878, although three hundred years previously Severino, and later Dieffenbach and Rhea Barton, had performed the same operation. Instead of Lister's transverse incision at the level of fracture, a longitudinal incision or a transverse incision not in line with the fracture is preferable. The blood should be removed from the joint as fully as possible, interposed tissues drawn out and excised, two or three holes bored through the fragments, and the latter drawn together with strong silk, catgut, steel, silver, or aluminum bronze wire, and the knots or twists sunk into the bone. The periosteum and fascia are closed by continuous or interrupted sutures. The skin is sutured and a splint applied. (Fig. 366.) Strict asepsis or antisepsis is the first requisite and indispensable con- dition; the wound should be 'fingered as little as possible — in fact, it is best not to touch the wound with the fingers at all, but to make the operation completely instrumental. In spite of primary union the results are not always satisfactory. Fibrous union may occur; the function may be impaired — that is, extension and flexion are limited. The same evil consequences as produced by protracted fixation in a plaster-splint may result, namely, shrinkage of the capsule, adhesions, atrophy of the quadriceps. Furthermore, it was found that fibrous union sometimes produced very little functional impairment in spite of a diastasis of some 3 or 4 inches, and that the patient was fully able to work. So Lister's operation was followed later, in the decade of 1S90, by the development of the treatment by early massage and mobilization, as recommended by Metzger, Tilanus, and others. This is in fact the application of the modern method of treating joint fractures to fracture of the patella. Careful massage is begun twenty-four to forty-eight hours after the injury, the joint as well as the muscles of the leg and thigh being treated; stroking upward aids the resorption of blood, tapotement and petrissage strengthen the muscles. The fragments are held meanwhile by an assistant. The faradic current may be beneficial. Gentle passive motion is begun in five or six days; in twelve to fourteen days the patient is allowed to get up and exercise, walking at first on crutches, then with a cane, and is usually discharged in six weeks. Some surgeons (Kraske, zum Busch) go still farther; they give up the idea of bony union from the outset, allow the patient to go about on the second day, walk up stairs after the eighth day, and report good results, zum Busch states that his patients were able to go about on the second day with a cane without crutches and were all able to work in four weeks; they could flex and extend the leg, walk without fatigue, climb stairs, and do the hardest exercises at the latest in six weeks, namely, with the injured limb they could mount a chair while standing close to it. Although these astonishing results show the great importance of massage and early mobilization, they are certainly not the rule, and few surgeons would decide to follow these extreme measures of zum Busch. The value of massage is unquestionably overestimated; it is chiefly useful in aiding the rapid resorption of intra-articular and periarticular FRACTURE OF THE PATELLA. 579 as well as intramuscular hemorrhages, and indirectly of preventing such hemorrhages from injuring the muscles, namely, by causing early atrophy of the quadriceps. Exercise alone can preserve and increase the muscu- lar tone. The favorable results reported by zuin Busch are therefore only possible with relatively slight tears of the capsule. If the "reserve" extensors are torn entirely or for the most part, the functional loss leads inevitably to rapid atrophy of the extensors in spite of massage and early use of the limb, as the observations of Soutter have taught, and the contraction of the muscles has the disadvantage of increasing the separation of the fragments and the difficulty of operative union later. To the author it seems to be all the more wrong to renounce the idea of bony union from the onset, because refracture occurs with distinctly greater frequency in the cases of fibrous than m those of bony union. Therefore it is always advisable to attempt to secure exact coaptation and union of the fragments by one of the above direct methods, but at the same time to prevent the bad results of protracted immobilization and disuse by instituting massage of the muscles at the outset, passive motion early, and active motion after about the twelfth to the fourteenth day. In cases with little tendency to separation of the fragments the joint may be aspirated and a splint may be tried first. If the fragments cannot be approximated after removing the blood, and there is evidence of a tear in the reserve extensors or of interposition of the periosteum, open suture of the bones is indicated. Trendelenburg recommended not to undertake operation until about eight days after the injury, in order to determine meanwhile the chances of recovery without opera- tion, and to allow the swelling of the soft parts to subside partially. If open suture is clearly indicated, there is nothing to prevent its being done in the first three days after injury. Up to the present opinion as to the best mode of treating patellar fractures has shifted from one point of view to another and has not yet become uniform. Whereas up to about eight years ago there was a tendency to limit more and more the indication of operation in favor of massage and movements, to-day, in view of the perfection of aseptic technic, the tendency is to do away with subcutaneous methods and expose and suture the fragments. One important advantage of suture over bloodless methods is that motion can be instituted much earlier without fear of separation. In compound fractures it is self-evident that the patella should always be sutured. Suture is indicated secondarily if bandaging is unsuccessful or the fracture has healed with weak, extensile fibrous union. On account of the retraction of the quadriceps it is often very difficult to approximate the fragments. If, with the muscles fully relaxed, the thigh flexed, and the knee extended, the fragments cannot be approximated with silver or silk sutures, the ligamentum patella 3 or the quadriceps may be divided, the latter by V-shaped or lateral incisions. Porter succeeded in approxi- mating the fragments in two old cases with considerable separation by dividing the fascia and quadriceps transversely through a transverse incision above the knee. v. Bergmann's method of chiselling off the spine 580 INJ URIES OF THE KNEE. of the tibia is better: with the knee flexed an incision is made below the spine and the same chiselled off obliquely upward; the joint is not opened. Even then it may be impossible to approximate the fragments, as in a case of Sonnenberg's. Various osteoplastic methods have been tried: Rosen- berger turned down a flap of the quadriceps tendon with a part of the upper fragment, turned up part of the ligamentum patella? with a piece of the lower fragment and sutured the two tendinous flaps together. Hel- ferich placed pieces of sterilized bone in the gap. Wolff bridged over the gap with bone-flaps chiselled from the upper and lower fragments. Tend- erich advised suture of the cap- TT QCV7 . A sular tear alone if the fragments could not be approximated, and cited a satisfactory result of thus repairing the reserve extensors. If the upper fragment becomes adherent to the condyles it usually demands excision. Appropriate after-treatment may give good results. If all measures have been ex- hausted and the limb is still dis- abled, an apparatus with strong elastic bands replacing the action of the extensors may be worn per- manently. Resection and a stiff joint are better for laborers who are compelled to carry heavy weights and who cannot afford expensive apparatus. This is a last resort, but a stiff joint is bet- ter than a limb which cannot be extended. The final result of every method often does not differ essentially from the conditions at the close of treatment. Few patients re- cover the full use of the limb; ac- tive extension is seldom complete, and flexion is often possible only to an obtuse or right angle. Ac- tive flexion and extension may be increased and strengthened dur- ing months or years by use, or, on the other hand, if a fibrous union gives gradually, work becomes more and more difficult after the first year and is finally given up. In Germany, on account of the accident annuity, it is often difficult to determine how far the disability is assumed or real. If actual, the thigh muscles are found to be atrophied, whereas with the full return of function the temporary atrophy dimin- Refracture of the patella three months after union by suture, due to slipping on the street. (Reichel.) RUPTURE OF THE QUADRICEPS TENDON. $%\ ishes and the thigh regains its normal size. Refracture occurs relatively often; it is most common within the first few weeks of resumed activity, and is almost always in the callus. (Fig. 367.) Later recurrence may involve the callus or both fragments, and may be in the form of a tear- fracture, or be due to direct violence like the original break. Rupture of the fibrous union may cause the joint to be opened, as noted by Malgaigne. The treatment is the same as that of the former injury; the fracture may heal by bony union. If dealing with a second rupture of a fibrous union and separation of the fragments, it is better to freshen up the fragments and suture them. RUPTURE OF THE QUADRICEPS TENDON AND THE LIGA- MENTUM PATELLA. Rupture of the quadriceps tendon and the ligamentum patella?, although less common than fracture of the patella, is closely related to the latter etiologically, as is easily understood from the fact that the patella merely represents functionally a large sesamoid bone interposed in the extensor apparatus of the leg. The mechanism of the rupture is not quite clear. Usually it is caused by forced contraction of the quadriceps to prevent falling; the tear therefore precedes the fall. Frequently, however, it results from direct trauma; but in many cases in which the patient falls upon the knee it is impossible to determine whether the fall is the cause or the result of the rupture. Occasionally no cause is recognizable; Maydl reports a case of rupture of both quadriceps tendons while the patient was standing still upon the steps, Yulpius a case in which the tear occurred while walking quietly on level ground. In the latter instance the tendon showed marked fatty degeneration. In another case of Yulpius', in which the ligamentum patellae was torn from the tibia, there was a sarcoma of the head of the tibia. The quadriceps tendon is ruptured somewhat less frequently than the ligamentum patella? and usually at its attachment on the patella, often with avulsion of small pieces of periosteum or bone. Tears at the muscular junction are less common, and are even more rare in the tendon itself. The ligamentum patellae is most apt to tear at or near its attachment on the tibia, less frequently at its insertion on the patella, very seldom in the middle. Important for the prognosis and treatment of both injuries is the circumstance that the piece of the tendon or ligament attached to the patella is liable to roll under between the patella and the femur and so prevent union without operative inter- ference. At the moment of the accident the patient feels an intense pain, hears a distinct snap, and is unable to walk. Active extension is lost or incomplete. If, exceptionally, the tendon alone is torn, the hemorrhage may be slight, and a gap i to f inch wide can be seen plainly at the point of rupture between the stumps of the tendon; through this cleft 582 INJURIES OF THE KNEE. can be felt the articular surface of the femur. As the tear usually extends more or less into the reserve extensors and the capsule, there is profuse hemorrhage in and about the joint and swelling; the gap can then be felt but not seen. If the ligamentum patella? is torn, the patella is displaced from h to 2 inches upward, a symptom which could only be mistaken for fracture of the patella, which, in turn, is excluded by measuring the length of both patella?. The gap can be felt below the patella. If the rupture is at the lower end of the ligament, the capsule may be uninjured; if the tear is higher up, the capsule is also torn and the joint fills with blood. Firm fibrous union may take place with complete restoration of function in either case, but frequently active extension is permanently impaired, the extensors atrophy, and a more or less pronounced limping gait is the result. Treatment. — The same treatment applies as in the case of fracture of the patella: Elevation of the limb upon a splint with the knee extended and the hip flexed, removal of the blood by compression and massage or eventually by aspiration, and early massage of the muscles. Many recommend early active motion. In tears of the ligamentum patella? one may try to draw down the patella by means of an appropriate bandage, as in the case of fracture of that bone. If asepsis can be assured, it is better to incise and suture; Blauel reports 28 cases, all resulting favorably. Tear Fracture of the Spine of the Tibia. — This results more often from a direct fall upon the knee than from muscular action, and is most common in adolescence. It may be a pure separation in the epiphyseal line; often, however, the line of separation lies only partly in the line of the cartilage. The fragment is irregular in shape and varies in size; it is drawn slightly upward by the quadriceps. In some of the cases the capsule is torn, but much less frequently than with rupture of the ligament. False motion and crepitus are easily demon- strated. Prognosis. — The prognosis is favorable. Treatment. — The treatment consists in drawing the fragment down to its normal position and fixing it by means of an appropriate bandage. The limb is elevated in a tin or wire splint, the extensor muscles massaged early and long immobilization avoided. Recovery is almost always complete. DISLOCATIONS OF THE KNEE. The infrequency of dislocations of the knee is due to the strength of the ligaments. They are produced only by great violence, such as a fall from a height, descent of heavy bodies, railroad accidents, entangle- ment in or blows from machinery; they are therefore often associated with severe injuries elsewhere. Fames reports forward dislocation occurring simultaneously in five miners who dropped 170 feet in the elevator of a mine-shaft. The author's knowledge of the mechanism DISLOCATIONS OF THE KNEE. 583 of origin is derived less from clinical observations than from experiments on the cadaver. The dislocation may be complete or incomplete, forward or backward, outward or inward. Forward and backward it is more often complete; laterally, incomplete. Dislocation Forward. — Forward dislocation is the most common form. (Fig. 368.) The cause, actually and experimentally, is forcible hyperextension, less frequently a blow upon the lower end of the femur from in front with the leg fixed. Fig. 368 * \ \ 1 '% \ \ i, Forward dislocation of the leg. (v. Bruns.) Symptoms. — The extensors and anterior portion of the capsule remain intact, the posterior portion, both crucial ligaments, and the greater part of one or both of the lateral ligaments at their points of attachment are torn. The condyles slide back on the tibia and their contour can be seen and felt in the popliteal space; the patella lies in the angle between the condyles and the condylar surfaces of the tibia; the joint is slightly flexed. The skin in front of the joint is thrown into folds; the limb is shortened, the anteroposterior diameter of the knee increased. Treatment. — Reduction in recent cases is generally easy by careful hyperextension, traction, and direct pressure. Dislocation Backward. — Backward dislocation can be produced on the cadaver only by placing a thick wooden wedge in the popliteal 584 INJURIES OF THE KNEE. space and hyperflexing. (Figs. 369 and 370.) It is usually caused by a blow from in front upon the leg while flexed. It is as often complete as incomplete. Symptoms. — The soft parts behind are stretched tightly over the head of the tibia and may be torn. The patella lies almost horizontally under the trochlea. The leg is slightly hyperextended. The antero- posterior diameter of the joint is increased. Its configuration is so characteristic that a mistake is hardly possible. The functional loss is absolute, although cases are known in which walking was possible later in spite of non-reduction. Treatment. — Reduction consists in flexion to a right angle, direct pressure forward, and then extension with traction in the long axis of the leg. Lateral Dislocations. — Lateral dislocations are more often incom- plete than complete, in outward dislocation the outer condyle lying upon Fig. 369. Fig. 370. Complete backward dislocation of the leg. (Hoffa.) the inner condylar surface of the tibia and the reverse in inward dislo- cation. At the same time the leg is often displaced forward or backward or rotated. In outward dislocation the internal lateral ligament is torn, in inward dislocation the external lateral ligament, the tear in the capsule always extending above it; if the dislocation is complete, the crucial ligaments are always ruptured; if incomplete, they are usually ruptured or badly torn. Instead of the lateral ligament tearing, the epicondyle or pieces of the condyle may be pulled off. In the cadaver lateral dislocations may be produced, after dividing the corresponding lateral ligament, by abducting or adducting the leg forcibly. Symptoms. — In the rare complete lateral dislocations the head of the tibia lies to the inner or outer side of the femur, the transverse diameter of the joint being doubled; the joint-surfaces can be felt easily through DISLOCATIONS OF THE KNEE. 585 the stretched or torn soft parts; the limb is shortened; the leg may depend loosely, and be capable of being Hexed and hyperextended passively; it is rotated either inward or outward. In the more frequent incomplete dislocation the stability of the joint is not entirely lost; the deformity and broadening are less marked, and are always masked by the verv large effusion of blood in and about the joint; the limb is not shortened, but the leg is abducted or adducted more than in the complete form. Diagnosis. — That the diagnosis may be difficult is shown by a case of Bahr's, in which after reduction in the ordinary way the knee could be flexed fully but remained stiff on being extended; the a>ray showed that the original inward dislocation had been changed to an incomplete outward dislocation by the reduction, the external condyle being caught in front of the outer tubercle of the spinous process. Fig. 371. COlMj- Roberts' case of dislocation of the knee outward with abduction. (Stimson.) Treatment. — Reduction is usually easy by traction — if necessary with accentuation of the existing adduction or abduction — and return to the normal position with appropriate pressure upon the joint. If left unre- duced, walking may still be possible, but the abduction or adduction usually increases. Rotation of the tibia is very rare. Wille could only collect 13 cases, of which 4 were complete, all outward, and 9 incomplete, some of these inward, some outward. They were usually combined with subluxation in some other direction. Complications. — The chief danger of all dislocations of the knee lies in the accompanying laceration of the soft parts. These are stretched to the utmost by reason of the size of the dislocated articular ends, and not infrequently tear at the moment of injury or during reduction or later become necrotic from the pressure of the edges of the bones. Thus a simple dislocation can become compound secondarily. Lacera- tion of the large vessels is even more serious; it may occur while the skin remains intact. 586 INJURIES OF THE KNEE. Lefiltiatre reports a case of backward and outward dislocation pro- duced by suspension, the foot being caught between the palings of a fence; all the ligaments were ruptured, the thigh being held only by the skin and a few muscles. One or both popliteal vessels may be lacerated, or the intima alone may be torn and thrombosis follow. Such lesions are particularly apt to occur in backward dislocation from the pressure of the sharp edge of the head of the tibia. Rupture of the nerves is rare; more often the function of the tibial and peroneal nerves is arrested by severe contusion. Laceration of both popliteal vessels is always followed by gangrene of the leg, and requires amputation. Rupture or thrombosis of the artery alone is usually equally disastrous, as the contusion of the surrounding soft parts, which goes with it, prevents the timely development of the collateral circulation. At first only a probable diagnosis may be possible in simple dislocation from the condition of the pulse in the distal arteries, for it is at this time that the symptoms of a traumatic aneurism, a tumor growing rapidly in the popliteal space, develop very quickly. A severe lesion of the artery is practically excluded by distinct pulsation of the posterior tibial behind the internal malleolus. Pulselessness should always arouse suspicion of partial laceration or thrombosis. The con- dition of the circulation of the foot and leg should be watched carefully for some time even after reduction. In the event of any of the above complications the prognosis for the first few days is doubtful or even serious; otherwise it is not unfavorable. Although some stiffness may persist for a time, full use of the limb usually returns in from one to three years. In the first few months one should watch for popliteal aneurism. Treatment. — If the skin is intact, it should not be injured in the reduction. After reduction the limb is enveloped in cotton and bandaged with moderate pressure, and laid and elevated in a long well-padded wire- or tin-splint. As there is little tendency to displacement, a plaster splint is not necessary, and is counterindicated by the swelling. In the absence of any circulatory disturbance regular massage of the knee and thigh is begun in three or four days, but not till the end of the second or third week if there is any suspicion of thrombosis of the popliteal vein; in the latter case massage should be limited to the parts at a distance from the vein to avoid loosening the thrombus. Mobilization of the joint is begun in the third week. If up, the patient should use crutches and wear a removable plaster- or silicate-splint; later a sheath splint hinged at the knee. Compound dislocations require the same strict treatment applied to compound fractures. Amputation is indicated if the popliteal vessels or simultaneously the sciatic or tibial nerves are ruptured or the muscles badly torn. Reduction is rendered easy in the majority of cases by the usually extensive laceration of the ligaments. It may be prevented, however, even under anaesthesia, by the tension of the soft parts, especially the extensors, or by interposition of portions of the capsule or by dislocated menisci; operation is then necessary, and has the advantage of allowing DISLiK-ATlnSs OF THE KSEE. 587 the blood to be removed from the joint. If one is certain of his asepsis, the incision may be closed; otherwise it is better to insert two lateral drainage-tubes. Habitual Subluxation of the Knee. — In conclusion should be men- tioned a rare affection resulting from a relaxed condition of the capsule. Robinson reports 3 cases of this sort in female infants under twelve months, whose general condition was poor. There was abnormal lat- eral mobility of the joint permitting of sudden outward displacement and rotation of the tibia; this occurred with a snap, and was reduced with equal rapidity on active motion. Recovery was effected by massage and by strengthening the general condition. Lissauer reports a case of voluntary dislocation following traumatic dislocation and reduction on the fifth day. Fig. 372. Congenital dislocation of the knee. (Stimson.) Congenital Forward Dislocation. — This is not an actual dislocation, but a congenital genu recurvatum, an abnormal hyperextension of the knee, as stated by Phokas, who collected 23 cases in 1891. The accom- panying illustration (Fig. 372) is an observation of Stimson's, and shows the characteristic attitude of the limb. The condyles project slightly backward, the skin in front shows several transverse folds. The patella is small but always present. Flexion actively is impossible, passively possible only to an obtuse angle, the leg springing back to the abnormal position if released. The dislocation is usually unilateral, very excep- tionally bilateral. The etiology and pathogenesis are not known posi- tively. Treatment. — The only treatment is to gradually flex the leg in plaster-splints until the normal position is attained and can be retained. 588 INJURIES OF THE KNEE. DISLOCATION OF THE PATELLA. Dislocation of the patella is really a displacement of the quadriceps tendon, although the former term is still retained. Surgeons distinguish: 1. Lateral dislocation. 2. Rotation about its long axis. 3. Dislocation downward in the cleft between the femur and tibia. Lateral Dislocation. — This form is most common, and is almost always outward. (Figs. 373 and 374.) Malgaigne reports one case of com- plete dislocation inward. The dislocation outward is incomplete or com- plete according as the patella is still in contact with the joint-surface or Fig. 373. Fig. 374. Complete dislocation of the patella outward. (Hoffa.) lies upon the epicondyle. Both forms occur with about equal frequency. The rarity of inward dislocation is attributed to the size and more rounded form of the inner condyle, the greater prominence of the inner edge of the patella, and therefore greater exposure to violence, and finally the slight physiological inward curvature of the limb as the result of which the extensor apparatus is too short normally to be displaceable over the inner condyle. Experimentally Streubel was unable to dislocate the patella inward, while it could be easily pushed outward with a carpenter's clamp. A blow or fall upon the inner edge of the patella is the usual cause of outward dislocation. In Malgaigne's case, a cavalryman, the patella was struck by his opponent in riding by. A sudden forcible contraction CD a < > x w < S, C < DISLOCATION OF THE PATELLA. 539 of the quadriceps is apparently more frequently the cause, especially if the knee is flexed and turned inward, as in wrestling or in falling. Genu valgum increases the predisposition. The hone is also displaced upward or downward slightly according to the nature of the force and the position of the knee in extension or flexion. The capsule is torn longitudinally along the inner side to an extent varying according to the completeness of the dislocation. In complete dislocation it may be torn the whole length of the anterior wall. The outer part of the capsule is thrown into folds, which can be felt at the side of the quadriceps tendon; the inner margin of the tear and the quadriceps tendon are visibly and palpably tense. The knee is bent inward and flexed slightly, and the ieg rotated outward; the patella forms a distinct projection at the outer side of the joint; the trochlea is empty and can be palpated. If the dislocation is incomplete, all these symptoms are less pronounced. Prognosis. — The prognosis is usually favorable. Even if the disloca- tion persists the use of the limb is gradually recovered, and hard labor is possible, but extension is limited and the genu valgum becomes more pronounced. Full recovery may follow early reduction. If used too soon, or if a serous effusion stretches the capsule, or the patient had a genu valgum before the accident, the dislocation may become habitual. Aldibert regards genu valgum as the most frequent cause of the dislo- cation. Chronic synovitis and weakness of the knee usually develop gradually and compromise the working ability of the patient. Treatment. — In recent eases reduction usually is easy, at least under anaesthesia, by flexing the thigh, extending the knee, and exerting direct pressure. Moderate compression is applied and the limb immobilized in a gutter splint; massage of the knee and quadriceps is begun after the third or fourth day, passive motion after five or six days, active motion in ten to fourteen days. An elastic knee-cap is worn for several weeks. Repeated dislocation requires longer immobilization, three to four weeks in a plaster-splint; habitual dislocation requires operation. Bandages if worn long are annoying and in severe cases are uncertain. Operation has given good results. If the capsule is relaxed on the inner side, a slightly curved longitudinal incision is made at the inner side of the patella, and an oval piece cut out of the capsule (Bajardi), or it is reefed (Bereaux, Le Dentu) the same as in Ricard's operation for habitual dislocation of the shoulder. If the cause is traction of the extensors in an improper direction, the spine of the tibia may be chiselled off, shifted to the inner side, and nailed. If genu valgum is the chief cause, it would indicate osteotomy or orthopaedic treatment. Congenital Dislocation of the Patella. — The rare congenital dislocation is treated the same as habitual dislocation if it produces disturbance. Bessel-Hagen distinguishes three forms: 1. Incomplete — the patella lies on the external condyle but slips into the trochlea in flexion. 2. Complete intermitting — the dislocation takes place in flexion but reduces in exten- sion. 3. Complete continuous — the patella, displaced outward, is dis- placed further in flexion. Secondary changes develop in the ligaments, 590 INJURIES OF THE KNEE. muscles, and bone. The external condyle becomes flattened and the corresponding half of the trochlea smaller or obliterated. (Appel.) Bessel-Hagen's 3 cases occurring in sisters would point more perhaps to faulty embryonal construction than to mechanical influences in utero. The dislocation may produce no functional disturbance for a long time; Schon saw a thirteen-year-old girl whose gait was at first unimpaired, but in whom gradually a pronounced genu valgum and habitual dislo- cation developed. Menard saw an eight-year-old boy whose left patella was rotated outward, and stood edgewise when the knee was flexed to a right angle; flexion further was impossible. Treatment. — The treatment is the same as that of habitual disloca- tion if the patella is troublesome. To prevent secondary disturbances, the patella should be secured in its normal position either by orthopaedic measures or by operation at about the fourth year. Vertical Dislocation of the Patella. — In this much rarer form the patella is always displaced laterally more or less and then rotated about its long axis until it stands edgewise in the trochlea. Lateral displace- ment is always accompanied by a certain degree of rotation, so that in every incomplete outward dislocation the outer edge of the patella is rotated forward. If this rotation is increased the other edge becomes caught in the trochlea, in outward dislocation the inner edge, in inward dislocation the outer edge, and the cartilaginous surface faces corre- spondingly outward or inward. This occurs inward or outward with about equal frequency. Exceptionally the rotation continues until the patella is completely reversed, the periosteal surface against the trochlea, the cartilage facing forward. Parker and Borchard each describe a case of complete outward dislocation of the patella with simultaneous outward vertical dislocation. The same causes are active as in lateral dislocation; a direct fall upon the knee with the limb strongly abducted (Vergaly); a blow upon the outer side of the knee (inward vertical dislocation, Link); sudden contraction of the quadriceps (Anderson); sudden rotation of the body about the long axis of the leg while standing (Gohlich). The patella is held in the vertical position, as shown by Streubel, by the tension of the folded and intact capsule on the side opposite to that toward which the cartilaginous surface is directed. Wolff's attempts at reduction by dividing the quadriceps tendon and ligamentum patellae subcutaneously were thus illogical and futile. The dislocation also pre- supposes an extensive longitudinal tear of the capsule on the opposite side; if complete, on both sides of the patella. In a case of Voigt's the patellar ligament was torn completely, the quadriceps tendon partially. Symptoms. — The knee is extended, the rotated patella projects forward; the quadriceps tendon, ligamentum patellae, and margin of the capsular tear are stretched tightly. In Gohlich' s case the foot was in a pro- nounced varus position. It is often difficult and equally important to determine which way the patella has rotated; the cartilaginous surface is recognized by the vertical ridge. DISLOCATION OF THE MEM SCI. 591 Treatment. — Reduction in many cases is very easy by relaxing the extensors, namely, flexing the hip and hyperextending the knee, and by manipulating the patella. In others it is difficult even under anaesthesia. It is a good plan to place the leg on one's shoulder. In difficult cases a hammer or carpenter's clamp has been used, but longitudinal incis ion and the use of an elevator or hook are better; some force may be required, or it may be necessary to divide the tense parts of the capsule. If the patella is completely reversed, operation may be necessary for diagnosis as well as reduction. If the patella cannot be turned over, it is excised. Recovery is often rapid; Link's patient was up in five days and discharged cured in ten days. Prudence demands somewhat longer treatment. Recovery may be delayed by chronic serous syno- vitis due to intra-articular effusion of blood. Dislocation Downward of the Patella.— This term has been recently applied to a so-called third form of dislocation, namely, downward with wedging of the patella between the femur and tibia. Only 4 cases could be found in the literature. The characteristic one was observed by Szuman; the extensors were intact. The patient had fallen under the iron oscillator of a chaff-cutter and had received several blows about the left knee: the quadriceps tendon was dislocated outward and the ligamentum patellae was partly twisted, but both were intact; the crucial and outer lateral ligaments were ruptured. The patella was wedged between the femur and tibia with its joint-surface facing upward. Reduction necessitated division of the ligamentum patella?. The final result was satisfactory. In the 3 other cases cited by Midel- fart, Deaderik, and E. Schmidt, the quadriceps tendon was ruptured at the patella, in the first case by falling upon a sharp stone, in the second by jumping on a moving train, in the third by slipping and falling upon a railroad track. In all 3 cases the patella was rotated on its transverse axis, wedged in the cleft of the joint, and prevented passive extension. Operation was successful in all. DISLOCATION OF THE MENISCI. Our knowledge of this not infrequent but previously unrecognized or disregarded injury has been greatly clarified and extended by v. Bruns' article, published in 1S92. After being contented for a long time with the diagnosis of a "derangement interne," dislocation of the menisci has become the subject of numerous investigations, so that the literature is now quite extensive. The lesion consists in a partial avulsion of one or both of the semilunar cartilages, either in front of or behind the spinous process, or somewhere along the attachment to the capsule or to the cartilaginous surface of the tibia. Exceptionally the meniscus is torn at its base from the capsule and forced into the joint, the anterior and posterior ends remaining attached. It is frequently divided into two or three pieces in a transverse or longitudinal direction. The internal meniscus is affected more than twice as often as the external, (v. Bruns.) 592 INJURIES OF THE KNEE. Symptoms. — The cartilage may not be displaced, and may unite again with sufficient rest; but very often it is displaced forward, back- ward, outward, or inward, becomes wedged between the joint-surfaces, and produces pain and impairment of function, and by the continual irritation inflammation of the synovialis and serous effusion. The lesion is usually due to some rather slight external cause, commonly a sudden forced rotary movement of the knee while the same is flexed. It occurs chiefly in young and muscular men. The inner meniscus is displaced by outward rotation of the leg with the knee flexed slightly or at a right angle, the outer by inward rotation, (v. Brims.) At the moment of the accident the patient feels an intense pain at the point of injury, which may be sufficiently severe to produce momentary syncope, after which the movement of the knee is impaired. There may be a slight intra-articular effusion of blood and moderate swelling. If the cartilage is merely torn and not displaced, or is displaced inward, nothing abnormal can be felt, but palpation is painful at the point of injury. If displaced forward or laterally, the cartilage may be felt projecting more or less distinctly. The effusion is absorbed rather rapidly and the symptoms subside in a few days, with rest, hot compresses, and massage. A certain amount of weakness, tenderness, and inability to extend or — if the outer meniscus is displaced — to flex the knee are left. The pain is increased by certain movements; frequently there is a slight synovitis. If the injury is not recognized, the patient may be disabled for years and be treated alter- nately with rest, plaster-splints or massage, medico-mechanical meas- ures, or hydrotherapy, till the proper diagnosis is finally made and the condition improved by operation. The patient sometimes calls the attention of the surgeon to a certain spot where the dislocated cartilage can be felt and moved, or the condition may be recognized only on careful palpation, or be surmised from the history and be established only by operating. In addition to traumatic avulsion of the semilunar cartilage, Allingham distinguishes a gradual loosening produced by the stretching of the capsule due to inflammatory processes. Such an etiology is not established positively, for trauma has usually preceded the condition, even years before, and the oft-seen inflammatory effusion in the joint is not to be regarded as the cause, but rather as the result of the dislocation of the cartilage. Treatment. — If recognized early, after reducing the cartilage the joint should be immobilized long enough to permit union. Reduction is only possible if the fragment is displaced toward the surface: The limb is placed in the position in which dislocation occurred, namely, in the case of the inner meniscus, by flexing and rotating the leg outward; while exerting constant pressure upon the projecting cartilage with one hand the leg is rotated strongly inward and extended quickly. The opposite procedure is performed in the case of the outer meniscus, namely, flexion and inward rotation; the limb is then immobilized upon a padded tin-splint or in plaster; later massage and passive motion; at the end of five to six weeks the patient is allowed to walk, avoiding the DISLOCATION OF THE ME SI SCI. 593 movements favoring dislocation — that is, walking with the foot turned outward if the outer meniscus was injured, and the reverse for injury of the inner meniscus. If the dislocation cannot be reduced or has existed for weeks, months, or years, operation is indicated: a curved longitudinal incision is made at the point of injury or transversely at the level of the joint, extending 3 inches backward from the margin of the pa- tella (Vollbrecht) ; the joint is opened, the displaced cartilage is drawn out with a small blunt hook and sutured in place with catgut if in good condition ( Allingham), or else removed. An entire meniscus has been removed without impairment, (v. Bruns.) If sure of one's asepsis the joint is closed; otherwise — and this is rarely necessary at the present time — a drainage-tube is left in for a few days. Both methods give good results if primary union is obtained. The excision of the meniscus is usually without functional loss. Patients who have suffered for years regain complete flexion and extension and the full use of the limb. To be sure, the result is not always so favorable; Nissen reports a case in which signs of arthritis deformans developed after two consecutive operations, in which the fragment and then the entire cartilage was removed. Bahr also saw less favorable results. As these appear to be rare, they do not form a counterindication to operation. Vol. in.— 38 CHAPTER XXXI. DISEASES IN AND ABOUT THE KNEE-JOINT. EXUDATIVE INFLAMMATIONS OF THE KNEE-JOINT. Acute Serous Synovitis. — Acute serous synovitis, although most frequently due to contusion or sprain of the joint, may follow open or subcutaneous injuries of the joint, especially puncture-wounds, or occur as a local manifestation of rheumatism, gonorrhoea, scarlet fever, smallpox, typhoid, and erysipelas — in the latter case especially if the process advances over the joint; also, after catheterization, dilatation of urethral stricture, lithotomy, or by transmission from an adjacent inflammation, such as furuncle or purulent prepatellar bursitis. The effusion varies considerably in amount, is often profuse, and is a yellow clear fluid containing albumin and a few white and, as a rule, a few red blood-cells; if due to severe trauma, the red blood-cells are increased, the exudation becoming yellowish-red or red with the charac- ter of a hremarthrosis. Fibrin may be present in varying amount, the serum being fiocculent, the cartilage and synovialis covered with deposit. The synovialis is injected, its villi slightly red and swollen, and after trauma contains a number of larger or smaller ecchymoses. The fluid may be resorbed and the joint return to normal in a few days, but unfortunately as the result of injudicious use the resorption is often only partial and the acute condition merges into a subacute or chronic one. Acute Seropurulent Synovitis. — The effusion is rarely purely serous, but rather seropurulent in synovitis of infectious origin, the leucocytes being increased, the serum opalescent or cloudy. This is seen in rheu- matism as well as in erysipelas, puerperal infections, or osteomyelitis of the femur or tibia. Acute Purulent Synovitis. — Purulent synovitis occurs chiefly after direct infection of the joint in wounds, gunshot fractures, or secondarily from a transmitted suppuration, as in purulent osteomyelitis of the epi- physis, rarely acute periarticular phlegmon. In the seropurulent as well as purulent form the synovialis is red and much congested ; the inner layer is greatly infiltrated with leucocytes; the villi are swollen and intensely red. The periarticular tissues are swollen, cedematous, and adherent to the skin; the contour of the joint is obscured. The capsule becomes intensely infiltrated with pus, ruptures, and phlegmon and fistulas follow. The perforation sometimes takes place in the upper recess, or at either side of the patella, or into the bursa poplitea or semimembranosa, with the formation of abscesses or fistulas between the muscles of the calf. ( 594 ) EXUDATIVE INFLAMMATIONS OF THE KNEE-JOINT. 595 The surfaces of the joint are involved rather early; the cartilage is destroyed in patches, replaced by granulations, and separated from the bone. The inflammation then spreads to the spongiosa of the femur, or tibia. Symptoms. — The picture of the serous synovitis depends essentially upon the effusion, the change in contour being the same as would be produced by injecting water into the joint; the depressions at the sides of the patella are replaced by swellings merging together above the patella and corresponding to the contour of the capsule, the "upper recess" extending even 2h to 3 inches above the patella. If the com- munication of the upper recess with the joint is narrow, the tumor is more hour-glass shaped. As the capsule is firm behind, swelling in the popliteal space is rare unless the exudate is very great. If the bursa? poplitea and semimembranosa communicate with the joint, there is a hemispherical swelling behind and toward the side of the joint. Fluctuation varies according to the size of the tumor; it is best obtained at the sides of the patella by pressing upon the upper recess. If the bursa? behind communicate with the joint, through-fluctuation may be elicited. With the knee extended and relaxed, the familiar click and ballottement — "Tanzen" — of the patella can be obtained ; in flexion the patella is always pressed against the trochlea even if the exudate is large. If the exudate is slight, the click can be elicited only by pressing all the fluid down beneath the patella; on the other hand, it may be prevented by the tension of a profuse exudate, but in this case the form of the swelling is characteristic. The soft parts are unchanged in the purely serous form; the skin is normal, but may be slightly warmer than the other knee. If the exudate is large, the knee is usually held slightly flexed, active extension being free, flexion slightly limited. Pain is absent or insignificant. The only functional disturbance may be slight fatigue on exertion and a weak feeling in the limb, especially in climbing stairs. Fever is absent in pure serous synovitis, especially when due to trauma, and present only in the infectious forms and in monarticular rheumatism, and then corresponds to the general infection or the inflammation adjacent to the joint- High fever, especially if continuous, if not explained by complica- tions elsewhere, always arouses suspicion of suppuration. The richer the exudate in leucocytes, the earlier the involvement of the tissues about the joint and the picture of acute purulent synovitis, as is usually seen in infected w r ounds of the joint. High continuous fever, between 102° and 104° F., is ushered in with one or more chills. The joint becomes painful, and motion and even the pressure of the bedclothes is avoided. The limb is soon flexed to a right or acute angle. The skin over the joint is red, glossy, and hot; the soft parts swollen and oedematous, concealing the form of the distended capsule. Fluctuation and ballottement of the patella, possibly under anaesthesia, confirm the diagnosis. The entire leg and foot may be oedematous if perforation occurs and phlegmon follows. The constitutional disturbance corre- 596 DISEASES IN AND ABOUT THE KNEE-JOINT. sponds to the height of the fever; there is headache, anorexia, malaise, vomiting; in severe cases septic diarrhoea, delirium, stupor or coma. v. Volkmann describes, under the name of catarrhal suppuration, an acute purulent gonitis, of which the cause is unknown, occurring in young children; the onset is spontaneous with fever and pain in the joint; the knee is flexed. Aspiration gives a tenacious pus, but instead of the usual periarticular phlegmon there is only slight oedema of the soft parts. The symptoms are less severe and recovery follows without incision. The gonitis resulting from metastases (pyaemia, puerperal fever, or erysipelas) often differs from the acute purulent process in infected wounds. There is fever, constitutional disturbance, a purulent or seropurulent effusion ; the joint may be destroyed early. But in con- trast to these severe anatomical changes the pain may be very slight, and the attention first aroused by the looseness of the joint and the backward dislocation of the leg. Movement of the joint is intensely painful, but stiffness is usually slight or absent. In contrast to the slight subjective disturbance aspiration will verify the presence of pus. Gonorrhoeal inflammation of the knee is rather frequent, only the wrist being affected as often. Therefore one should not be too pre- vious with the diagnosis of monarticular rheumatism, for the supposed rheumatism often proves to be a sign of gonorrhoea. Baur found the gonococcus in 60 per cent, of the cases of gonorrhoeal synovitis up to the sixth day of the disease, but this does not exclude the possibility that a non-gonorrhoeal or mixed purulent gonitis may occur during gonor- rhoea. The knee may be involved secondarily at any time during the urethritis, but usually it is affected in the first week, exceptionally after the disease has existed some time. The cessation of the urethral discharge with the onset of the gonitis and its recurrence after the latter has subsided, although observed frequently has not been ex- plained. The inflammation may be serous and subside in a few days under appropriate treatment, or purulent, the effusion being cloudy from the first with leucocytes and fibrin, the capsule and cartilage being covered with deposit. On incising the joint the fibrin may be removable in large strips. Occasionally the effusion is entirely purulent; the soft parts are swollen early, the ligaments and capsule infiltrated with leucocytes, the skin and subcutis cedematous. The effusion may be slight or profuse, and so suggest tuberculosis, especially if of long standing. The pain is very intense. At the onset fever is common. Profuse exudation with distention and destruction of the capsule are liable to be followed by backward subluxation of the leg. If the exudate is slight, stiffening is probable — in fact, is often unavoidable, on account of the shrinkage of the capsule and the adhesions between the joint- surfaces. The cartilage is destroyed early by the fibrin deposits, the bone becomes involved; fibrous or even bony ankylosis may follow in a few weeks, the patella especially being liable to become adherent to the condyles at an early period. The disease is therefore serious, its prog- nosis doubtful, and the treatment very important. /.A r DATIVE INFLAMMA TIONS OF THE KNEE-JOINT. 597 Course. — The course of the various exudative inflammations of the knee-joint depends essentially upon the nature and severity of the disease and upon the treatment. Simple acute serous synovitis usually heals in a short time unless the joint is not rested properly, in which case a chronic hydrarthrosis may result and more or less fluid remain in the joint or return every time the limb is used. The synovialis then becomes more thickened; the villi are enlarged and often contain cartilage-cells; the cartilage becomes somewhat fibrous; the exudate is thin with few cells. Chronic hydrarthrosis is recognizable chiefly by the swelling in the joint and the absence of such about the joint. Fluctuation and bal- lottement of the patella are easily obtained; subjective symptoms are slight; pain may be absent or be produced by pressure and motion. The mobility of the joint is seldom impaired; the patient merely has a feeling of weakness and uncertainty in the limb and is unable to lift heavy weights. But the earning-efficieney is thereby considerably compromised. Objectively the early atrophy of the quadriceps and weakness of the limb are noticeable; later, after the ligaments have become relaxed, the looseness of the joint, especially the lateral mobility possible with the knee extended. Complete recovery cannot be expected if the exudate is not purely serous, unless treatment is begun early, except in the cases of so-called catarrhal suppuration in children. The seropurulent and purulent forms, even with proper treatment, are usually followed by a certain amount of stiffness whose removal may be more or less effectually accomplished by proper treatment, exercise, and use, but which nevertheless makes demands upon the physician and patient that are not always met. One is fortunate if able to prevent a contracture, backward dislocation, a varus, or, more commonly, a valgus position and the consequent severe functional disturbance. The tendency of gonorrhceal gonitis to fibrous or bony ankylosis has been mentioned. In the severe forms of septic suppuration following wounds, osteomyelitis, etc., early energetic treatment is required to preserve even a fair amount of motion. If the cartilage is eroded or destroyed, the final result should be considered good if the patient has a stiff but useful limb with the knee extended after resection. Treatment. — The majority of surgeons at the present time treat exudative gonitis in about the same way. Immobilization in a plaster- splint is seldom employed except in very painful cases with slight or no effusion. The acute serous effusions as a rule only require rest for several days in a tin- or wire-splint, with the application of moist heat and pressure. Konig applies tincture of iodine thickly till the skin is dark brown, and then an ice-bag. As soon as the effusion is resorbed gentle passive, and then active, motion is begun, but the patient is not allowed to walk until motion is without pain. Salicylic acid is some- times beneficial the same as in polyarticular rheumatism. If resorption is delayed or a seropurulent effusion is manifested by fever, periarticular swelling and intense pain, aspiration with a large needle, or, better, a trocar, is indicated, preferably at the outer side of 598 DISEASES IN AND ABOUT THE KNEE-JOINT. the upper recess; a 2 to 3 per cent, solution of carbolic acid is then injected, allowed to escape entirely, and the puncture-wound sealed with iodoform collodion. Many prefer the injection of 10 to 20 drops of tincture of iodine, of 1 to 2\ drachms of Lugol solution, or of 1 to 2\ drachms of iodoform-glycerin emulsion. The latter has given the author very good results. A dressing is then applied with slight pressure and the limb immobilized on a strip splint for three to five days; later, careful motion and massage. As a rule the injection or lavage is followed by slight rise of temperature for one or two days. If suppuration finally develops or is suspected at the outset, it is advisable to puncture to verify the diagnosis, and then to incise and drain. Two longitudinal incisions (f to \\ inches long) are made at either side of the quadriceps tendon, the upper recess is opened, and two incisions also made below the patella in front of the lateral liga- ments. The joint is washed out thoroughly with a 3 per cent, boric acid or salt solution, a large drainage-tube inserted transversely through the upper wounds, and two shorter ones in the lower openings not long enough to be caught between the joint-surfaces. A dry dressing is ap- plied and the limb placed in a Volkmann splint. Exceptionally it is necessary to drain posteriorly; Oilier makes two lateral incisions behind the condyles, the outer at the anterior border of the biceps tendon, the inner between the semitendinosus and semimembranosus, and in severe cases recommends opening the joint in front and removing the crucial ligaments. The incision behind may be made by dissecting through the popliteal space. In such severe cases free motion is not to be expected. Instead of the above customary four short incisions, two long lateral incisions curved convexly backward may be made at both sides of the extensors and the joint opened in its entire length; instead of draining, the cavity may be packed loosely with iodoform gauze. Resection is indicated if the joint-surfaces are destroyed and the cartilages detached as in cases of fracture with suppuration — for exam- ple, gunshot fractures. Ankylosis is inevitable. Amputation is indi- cated by rapid extension of a local septic infection or by symptoms of general infection. Attempts to preserve the limb by incision and drainage or resection in such dread cases are usually paid for with the life of the patient. It is therefore very important not to carry con- servative treatment too far. The contracture left after exudative synovitis offers a varying amount of resistance to treatment. In the mild serous cases it is naturally slight, and usually disappears rapidly with use; in the seropurulent or purulent cases with fibrin, especially the gonorrhceal cases, it may be very stubborn and be overcome only by persistent and continuous methodical exercise. Passive and active motion should be gentle at first, and increased daily according to the pain and reaction. At the beginning the joint is bandaged each time after being exercised and a hot wet compress applied regularly at night. Renewed effusion may follow the first active exercise, especially after protracted immobili- zation ; if slight, it should not prevent careful use ; otherwise, if EXUDATIVE INFLAMMA TIONS OF THE KNEE-JOINT. 599 marked and accompanied by fever, immobilization and aspiration are indicated. The intense pain often produced by passive motion may delay recovery or prevent further treatment in the ease of sensitive people without will-power. Nevertheless unexpected improvement may occur even in such patients in the course of a year or more; in others stiffness ensues. As bony ankylosis becomes established, the use of the limb becomes less and less painful; on the other hand, a joint stiffened by fibrous adhesions with a mobility of perhaps 10 to 30 degrees is often extremely sensitive and disables the patient for a long time. Forcible separation of the adhesions may be attempted under anaesthesia, the joint then being wrapped in wet compresses and immobilized for twenty-four to forty-eight hours, but success presupposes a patient with a strong will and ability to endure the protracted pain of subse- quent treatment. On account of this difficulty of overcoming estab- lished stiffness the mobilization of the joint should be begun at the earliest possible moment, namely, a few days after aspiration or lavage, or after incision, as soon as the fever disappears and the pain becomes tolerable. The time must be determined in the individual case. Chronic Synovitis. — Simple hydrarthrosis is favorably influenced by pressure by means of a rubber bandage, as in the case of rnemarthrosis, or sponges, but is liable to return as soon as the pressure is discontinued. Lavage of the joint with a 3 per cent, carbolic acid solution deserves more general use; the joint-capsule should be moderately distended and manipulated and the joint moved to bring the fluid in contact with all parts of the affected capsule; the solution is then aspirated and fresh injected until it returns clear. It is then entirely expelled by light pressure and a pressure-bandage applied and w r orn for about eight days. Not infrequently the fluid reaccumulates in five or six days, even while the patient is in bed and the joint under pressure; if it does not disappear under massage and pressure, a second or even third wash- ing may be necessary. The effusion not infrequently yields to this treatment if the case is not too old. Since this procedure was intro- duced by v. Volkmann the injection of tincture of iodine (Bonnet, Vel- peau, and others) has been less used; with the latter there w r as always a strong reaction — pain, marked swelling, redness, and slight fever for one or two days. Still, the method has given good results in many stubborn cases in which other measures failed, and should therefore be remembered. Injection of 10 per cent, iodoform-glycerin (iodoform oil) has often been successful in non-tuberculous cases; the irritation is slight. For several weeks after puncture the knee should always be bandaged with flannel, or a woven or elastic knee-cap worn. In severe cases it is better to have the patients wear and go about in a silicate- splint or a leather sheath supporting apparatus. Heidenhain recom- mended Unna's zinc-gelatine dressing (Zinkleim Verband); it is very serviceable for clinical or poor patients. Intermittent Hydrops. — Intermittent hydrops is a rare form of exu- dative synovitis of the knee which is little known and the nature of 600 DISEASES IN AND ABOUT THE KNEE-JOINT. which is still unexplained. Two years ago Benda could collect only 56 cases of this sort; it occurs chiefly in the knee-joint and in one or both knees, with the symptoms of an acute serous synovitis; in 14 instances the knees were affected consecutively. The peculiarity of the affection is its periodic recurrence at intervals of eleven to thirteen days, less frequently of seven to nine days, or of four weeks; single instances of other variations are given. The swelling usually lasts three days; occasionally also associated with swelling of the skin of the thigh or face. Shortly after the fluid has disappeared, or even before, a new attack occurs without apparent cause. Rapidly following attacks cause a certain amount of fluid to be left permanently. The number of attacks varies greatly, their frequency and course being little influenced by treatment. They may cease as suddenly as the first attack appeared and not recur for many weeks or months. Little is known positively as to the cause of this peculiar affection or its striking periodicity. There is apparently no latent malaria as one might suspect; disturbances of the nervous system seem to play a cer- tain part in the etiology. Local treatment is practically powerless to prevent new attacks, so that one is dependent chiefly upon the general treatment; quinine, arsenic, potassium iodide, warm baths, hot spring baths, and hydrotherapy have been useful in some cases, but just how is hard to determine, as spontaneous recovery has also occurred. The affection may kst for years and cause severe functional disturbance. TUBERCULOSIS OF THE KNEE-JOINT. All the forms and peculiarities of joint-tuberculosis occur with such frequency in the knee that this joint is the best for studying tuberculous arthritis, with the exception of the rare caries sicca. Children and adolescents are most commonly affected. According to Konig's statistics of 704 patients, 292 were in the first decade, 190 in the second, and 93 in the third, males being affected (59 per cent.) somewhat more fre- quently than females (41 per cent.). The right and left knee were apparently diseased equally often. As to the origin being in the syno- vialis or the bone, authors are not agreed; Konig estimates 281 cases as being osseous, 351 as synovial, and 29 as undeterminable, among 661 cases. Slight trauma, simple contusion, and sprain are given as the cause in about 20 per cent, of the cases; usually there is evidence of heredity or tuberculous foci elsewhere. Pathological Anatomy. — In tuberculosis of the synovialis, whether primary or secondary, the changes are the same as to quality and vary only in as far as the effusion or the granulations predominate. The process apparently starts as a rule with the increased production of synovia rich in fibrin, the fluid rarely being as clear as that of serous synovitis. It may be slight or so profuse as to be termed properly a tuberculous hydrops. From the onset it is more or less cloudy, the particles of fibrin varying from the finest flocculi to large flakes and TUBERCULOSIS OF THE KNEE-JOINT. 601 threads which may coalesce to form firm or soft grayish-white masses of round or oval shape, the size of a pinhead, pea, or bean, the so-called rice-bodies. In the early stage the synovialis is red and swollen; the cartilage is covered at typical spots with thin transparent membranes spreading out over the synovialis from the junction of the cartilage and capsule, the typical spots being on the lower front surface of the condyles of the femur below the patella, where the trochlear surface joins that of the condyles, namely, at the point where the cartilages of the femur and tibia are not in contact. This fibrinous deposit later becomes vascular and dotted everywhere with tuberculous nodules, but especially along the edges of the cartilage. (Konig.) The synovialis and cartilage thus become covered with granulations. Goldmann and others, against Fig. 375. Surface of the femur divided into three parts by granulation-tissue. CKiinig.) this view of Konig's, believe that the changes are due to degeneration of the synovialis. The process may be localized and limited to one or more portions of the joint, the cartilages becoming adherent and the foci walled off, or the cartilage and bone may be destroyed progressively. (Fig. 375.) At one or more places on the synovialis there may be a circumscribed, or diffuse, and often exuberant, proliferation of the villi, forming grayish-red, or gray, fairly firm polypoid growths of various shapes and sizes. (Fig. 376.) Their groundwork consists of connective tissue and vessels; the subsynovial adipose tissue may be involved in the growth, even to the extent of forming tumors almost entirely com- posed of fat (lipoma arborescens ) . In rare instances there is a circum- scribed, nodular, tumor-like proliferation of connective tissue at one or more spots on the synovialis, the so-called tuberculous fibroma (Riedel, Konig), attaining the size of a walnut, and consisting partially of fatty 602 DISEASES IN AND ABOUT THE KNEE-JOINT. degenerated connective tissue or of tuberculous nodules separated by a large number of thick-walled vessels. The cartilage is apparently passive in the process; at first it loses its normal gloss and smoothness, then shows small defects, which as the granulations develop become more numerous, spread, and deepen until the cartilage is finally perforated in places. In these spots the granu- lation-tissue attacks the bone. The granulations also advance between the cartilage and the bone, especially at the attachments of the lateral ligaments, loosening the cartilage from its base until it is often completely Fig. 376. Growth of synovial villi in tuberculous knee-joint. (Konig.) destroyed. (Fig. 377.) The spongiosa of the bones undergoes a rare- fying ostitis, which, according to Konig, may not be tuberculous ; it may occur in the absence of primary foci in the bone or without the tuber- culous granulations having perforated or undermined the cartilage. Once having penetrated into the bone the process produces the same changes found in the primary tuberculous granulation foci. Primary tuberculosis of the bone is seen in the condyles of the femur, the tuberosities of the tibia, and less frequently in the patella, in which latter it is either in the form of a granulating focus or a sequestrum, rarely a progressive infiltration. Large wedge-shaped sequestra are TUBERCULOSIS OF THE KNEE-JOINT. 603 met with in the tuberosities of the tibia, with the base usually toward the joint, and occasionally in the condyles of the femur; the cartilage is rapidly destroyed, but if the joint is used, the surface becomes polished. Perforation of an osseous focus into the joint depends upon its relation to the capsule; the majority of foci lead secondarily to tuberculosis of the synovialis, although extra-articular perforation does occur. A typical focus, frequently advancing outside of the joint, is found in the head of the tibia, perforation usually taking place either forward into the subpatellar bursa beneath the attachment of the ligamentum patella?, or laterally below the insertions of the semimembranosus and tendinosus, or, rarely, behind into the popliteal space; perforation into the joint alone or combined with perforation outward is not rare, however. Fig. 377. Deep destruction of cartilage and bone in the area covered by deposits, with numerous foci of necrosis. (KiJnig.) Primary foci in the epicondyles may perforate laterally or backward without infecting the capsule; if forward or downward, the joint is necessarily involved. Foci in the patella, although they often perfor- ate forward, lead rather frequently to secondary tuberculosis of the synovialis, either directly or by the formation of a periarticular abscess. The site of the osseous foci was found by Konig, in 281 cases, in the patella in 33, in the femur in 93, in the tibia in 107, and in several bones in 48. The fibrous capsule of the joint forms a protective wall against the dissemination of synovial tuberculosis, so that the process cannot perforate unless suppuration occurs; this is never the case in simple tuberculous synovitis. Perforation, although it may take place at any point, is most frequent at the upper recess, at the sides of the patellar ligament, and behind into the bursa poplitea or semimembranosa. Cold abscesses, often very extensive, may then form either in front beneath 604 DISEASES IN AND ABOUT THE KNEE-JOIST. the vasti or behind beneath the muscles of the calf. Periarticular abscesses which do not involve the joint are apparently always the result of perforation of primary osseous foci; such abscesses have often been incised and scraped out, however, without any diseased bone being found, and have recovered. Synovial tuberculosis may recover at any stage if transformed into connective tissue with shrinkage of the granulations, but rarely if there is extensive caseation of the fibrin or suppuration, although even then it is not impossible. Large osseous foci retard recovery; large sequestra make it impossible, although temporarily there may be an apparent recovery. Normal mobility is rarely restored except in very mild cases in youth, the destruction, partial or complete, of the articular surfaces, the adhesions and the shrinkage of the capsule, always entailing more or less functional loss. Symptoms. — Clinically, primary osseous and primary synovial tuber- culosis are very seldom distinguishable from each other. The former gives almost no symptoms; usually there is only slight dull pain, increased by pressure, until the joint becomes involved and the synovitis produces symptoms and discomfort that cause the patient to seek medical aid. The osseous form is occasionally diagnosed before the synovialis is involved if the focus is superficial and the bone is thickened or cold abscesses have formed. This applies especially to foci in the head of the tibia, to those in the patella in which the focus perforates forward, and to circumscribed foci in the epiphysis of the femur perforating laterally outside of the joint. The clinical picture is dominated by the synovial tuberculosis, whether primary or secondary. Three varieties are distinguishable: (a) tuber- culous hydrops; (b) granulation tuberculosis or fungus of the joint; (c) cold abscess of the joint. Although the three forms merge into each other, this classification is valuable practically. The tuberculous hydrops is characterized by the effusion, and is essen- tially the same clinically as serous synovitis, already described, so that the tuberculous nature of the affection is indicated less objectively than bv the accompanying moments, namely: 1. The youth of the patient, simple hydrops occurring chiefly in adults, although it occurs excep- tionally in youth even as the tuberculous hydrops is often seen in adults. 2. Tuberculous heredity. 3. Scrofulous habitus or the existence of tuber- culous processes elsewhere. 4. The appearance of the effusion sponta- neously without fever, or after slight trauma, contusion, or sprain; the exclusion of gonorrhoea, arthritis deformans, or previous rheumatism. 5. The persistence or constant recurrence of the effusion in spite of the appropriate treatment to which simple hydrops usually yields. None of these facts is conclusive per sc, but taken together, especially after longer observation, they make the diagnosis probable. In some cases the -welling is more positively tuberculous; usually the capsule is more distended than in simple synovitis, the thickening being most distinct in the lateral folds or the upper recess. By stroking the fluid from the sides into the upper recess or in the opposite direction a soft rubbing TUBERCULOSIS OF THE KSEE-JOIST. 605 can often be felt, and by moving the joint a distinct " snow-hall crunch- ing" or coarse crepitation of the larger rice-bodies. The aspiration of cloudy fluid filled with fibrinous flocculi is positive. The fungous variety, according to Konig, represents the second stage of the disease, and is always preceded by the hydrops. Although Konig has seen many such cases, it is questionable whether this sequence always occurs, as one meets with cases enough giving only the symptoms of granular proliferation without any evidence in the history of previous hydrops. In the fungous form there is always some effusion, but it is insignificant compared to the granulations and consequent thickening of the capsule. The upper recess is therefore not so sharply defined; the uniform swelling of the capsule is more noticeable at the cleft of the joint. This, in connection with the early atrophy of the muscles, especially the quadriceps, gives the spindle-form so characteristic of "fungus." Or the process and the thickening may be limited to some part of the joint and give an appearance similar to that of sarcoma of the condyle. Generally, however, the circumscribed as well as the diffuse swelling is not very sharply defined, although one can feel the folds, namely, the attachments of the synovialis, very distinctly in cases in which the structures about the joint are still uninvolved. The consistence of the tumor is usually firm. Fluctuation and bal- lottement of the patella are absent. The cases with very exuberant and rapid formation of granulations with caseation and suppuration are not rare; the swelling often resembles that of simple hydrops in form and consistence, the upper recess being distended and often giving pseudo- fluctuation from the softness of the granulations. If caseation and suppuration develop, the inflammation spreads rapidly to the fibrous capsule and the tissues about the joint, which become oedematous, thickened, and augment the characteristic spindle- form; the skin becomes thinner, pale, glossy, and the subcutaneous veins more distinct. To this picture of fungous inflammation the very appro- priate term "tumor albus" was applied formerly. The function of the joint is little impaired by the hydrops, only the extreme movements being impossible, whereas, in fungous tuberculosis motion is considerably limited and a contracture in slight flexion occurs early. The degree of flexion varies; exceptionally — in fact, only in the event of suppuration — the knee is soon flexed to a right angle, or further, as often observed in the cases of acute suppuration of the joint; usually it remains flexed at an angle of about 130 to 1G0 degrees for a long time, the angle gradually becoming more acute. The limb is held fairly immovable in this position; active motion is avoided or limited; passive motion usually evokes strong muscular resistance, motion being greatly limited, however, even under anaes- thesia, by the intra-articular adhesions and shrinkage of the capsule. Beside flexion there is usually a varying amount of abduction and out- ward rotation, namely, a valgus position. This is found also with pure synovial tuberculosis, so that destruction of the bones of the joint can be presumed therefore only from a high grade valgus position of rapid 606 DISEASES IX AXD ABOUT THE KNEE-JOINT. development. Persistence of the contracture leads regularly to erosion of the contiguous surfaces of the femur and tibia, chiefly the outer posterior portion. A varus position is more rare; if pronounced, it always denotes destruction of the inner condyle or tuberosity or both. The rare genu recurvatum and frequent backward subluxation of the leg, which are a result of the disease and the treatment, rather than a part of the disease, will be described later. In spite of the contracture the patient may be able to use the limb for a long time. The pathological position is chosen and maintained by Fig. 379. Acute tuberculous arthritis of the knee. (Whitman.) Tuberculous disease of the knee in an adult. The synovial type. (Whitman.) the patient to a certain extent to alleviate the pain, and is therefore an expression of the painfullness of the joint; in fact, the valgus position is to be regarded partly as a direct consecutive-symptom of the weight- ing of the limb flexed at the knee. In some instances the limb is pro- tected from the outset by using crutches or by staying in bed; in others the patient limps about with a cane for months or years. This differ- ence is due not only to the varying will-power or negligence of the patient, but also to the fact that the pain differs in individuals. TUBERCULOSIS OF THE KNEE-JOINT. 607 As mentioned, complete absence of effusion is rare in a tuberculous knee-joint; in about one-half the cases it is purulent. Caseation and purulent fusion take place first in the unorganized fibrinous deposits or granulations upon the synovialis or cartilage. The abscess thus formed may perforate directly outward through the fibrous capsule and lead to a periarticular abscess without the joint necessarily containing pus; more frequently it perforates into the joint alone or outward at the same time. In the joint the suppuration may be circumscribed or diffuse. The cause of suppuration is still unknown, disregarding infection by aspiration, etc. In the absence of fistulas or periarticular abscesses the diagnosis of tuberculous joint suppuration is usually uncertain. Continuous slight fever in the absence of other causes makes it probable, the temperature usually being normal or only slightly increased in the morning, in the afternoon varying between 100.4° and 101.2° F. The general condition suffers, the appetite decreases, the skin becomes pale, the patients lose slowly but visibly. After perforation outward and the formation of a fistula the fever sometimes disappears, the patient improves, the process comes to a standstill. Often secondary infection occurs, however; the pus putrefies and becomes foul, and the fever becomes continuous and high with the signs of local and general sepsis. Cold abscess of the joint, although rare, is not to be confused with the frequent suppuration of the fungous joint; it is less frequent in the knee than in the hip, and occurs chiefly in young children other- wise tuberculous; it is occasionally bilateral. The synovialis is only slightly swollen, but filled with miliary tubercles; it is covered with a thick loosely attached abscess membrane and greatly distended by a thin fluid effusion. The form of the joint is similar to that in hydrops, and likewise lacks any tendency to perforation and periarticular phleg- mon. The diagnosis may be difficult, especially as fever may be absent, but is usually aided by the poor general condition, multiple lesions, youth of the patient, and the marked swelling of the synovialis; aspiration also helps in doubtful cases. Course — Spontaneous recovery may occur at any stage of tuberculosis of the knee-joint except with very large osseous foci or sequestra; it is prevented by suppuration of the granulations. Hydrops and the fungous variety with dry compact granulations which have a tendency to shrink- age give the best prospects of recovery; they may heal possibly in one to three years, although very often the disease lasts considerably longer and the recovery is only apparent, the slightest blow often sufficing to occasion renewed pain and lighting up of the old process. That such apparent recovery is seen rather frequently can be readily understood from the pathological conditions, the limitation of the process to certain areas of the joint. Recovery is very rarely ideal, namely, with the func- tion fully preserved. Konig saw such in only about 7 per cent, of the cases. One usually has to be satisfied if the recovery is accompanied by impaired motion, possibly a stiff but still useful limb. From the above description of the anatomical changes it is obvious that in fun- gous tuberculosis as well as fibrinous hydrops the mobility of the joint 608 DISEASES IN AND ABOUT THE KNEE-JOINT. Fig. 3S0. must suffer as a result of shrinkage of the granulations, and thereby of the capsule, and fibrinous or even bony adhesion of the various portions of the contiguous joint-surfaces. The contracture position is more frequently the cause of impairment than the partial or complete stiffness of the joint. A flexure is most frequent after spontaneous recovery as well as after conservative treat- ment or operation; it is often combined with a valgus position. Backward subluxation is the most common of the other anomalous positions, and is usually due to an improper and forcible attempt to correct the flexion contracture. The head of the tibia may slide back- ward gradually upon the condyles of the femur from the weight of the leg if the capsule, and especially the crucial ligaments, are destroyed and the knee is bandaged in flexion upon a splint and not properly supported. The shrunken posterior portion of the capsule holds the condylar sur- faces of the tibia firmly against the posterior surfaces of the condyles and prevents the extension necessary to stretch the contracture about an axis running transversely, not through the cleft of the joint, but through about the middle of the condyles. If for- cible extension is attempted, the front border of the head of the tibia is pressed against or even into the soft bone of the femur, the posterior bor- der pushes against the capsule, tears it off or tears through it partially or completely, and the subluxation is accomplished, the long axis of the leg being parallel to but behind that of the thigh. In some instances the same attempt fractures the tibia or the femur through the epiphysis and produces a bayonet deformity. Genu recurvatum, a hyperextension position of the leg, is seen very rarely as the result of extensive destruction of bone or resection; in the latter case due either to oblique division of the bone or inappropriate after- treatment. Arrested development occasionally produces functional impairment in young subjects. In the florescent stage of joint-tuberculosis in children from two to nine years old Pels Leusden demonstrated with the .r-ray a lengthening of the affected limb due to the increased growth of the shaft of the femur. The majority of authors are agreed that shortening is more frequent if the disease is protracted, and that it is Deformity and shortening resulting from ex cisionof the knee in childhood. (Whitman.) TUBERCULOSIS <>!■' THE KNEE-JOINT. 609 due partly <<> destruction of the epiphyseal line by the process or by necessary operation and partly to disuse. It is usually from 1 to I \ inches, hut exceptional eases of 8 inches are known. As early as the florescenl stage the diameter of the femur is diminished as a rule. Konig's recent statistics of tuberculosis of the knee-joint are as follows: Of 615 patients treated in the Gottingen clinic from 1875 to IS*.)!!, and watched later, 205 (33.3 per cent.) died; of these, SI per cent, died of the various forms of tuherculosis. Of 703 patients, only 18 succumbed to infectious diseases or poisoning by iodoform, chloroform, or carbolic acid. Of those in which suppuration occurred almost one-half died, and of those without suppuration about one-fourth. Four hundred and thirty were well when these statistics were collected. Treatment. — The question as to conservative or operative treatment of tuberculosis of the knee-joint is still unsettled. After a discus- sion lasting through two decades a uniform opinion is hardly to be expected as the material of individual surgeons, the hygienic surround- ings, and the consequent results of treatment vary too much. The period of almost purely operative treatment following the introduction of antisepsis has been followed by one or more conservative methods, the latter being superseded at the present time by almost ultracon- servatism in not a few places. It is only in a few of the cases, namely, those in which the age and poor general condition of the patient, the high fever due to mixed infection, and severe destruction of the joint, etc., are counterindications, that conservative treatment is without prospect and resection or amputation is to be considered. In the large majority of cases conservative measures will be adopted, varying some- what according to the view of the individual surgeon, although very often operation will be necessary later. The most important and effectual element of conservative treatment is absolute rest of the limb with the knee extended. A flexure or an abduction contracture is overcome if slight and recent by manual correc- tion under anaesthesia: By gradual steady traction and pressure the leg is extended and adducted, avoiding extension in the improper axis described above. A plaster-splint is then applied. If the straightening is not com- plete, it is repeated in two to three weeks, and again later if necessary. Continuous extension is usually preferable if the correction is diffi- cult, the desired result being obtained in two or three weeks; in the case of children 10 to 25 pounds being used, and in adults, if the process is not too old, 20 to 35 pounds. Any remaining flexion or abduction is generally overcome easily and without danger under anaesthesia. The technic will be found under contractures. Many prefer to continue the extension later to separate the joint-surfaces, the favorable influence of which has been demonstrated beyond question. It seems to the author, however, that once having corrected the position the immo- bilization assured by a circular splint is more important than the "distraction" of the articular surfaces. A portable plaster-splint is preferable, to the author's mind, on account of its simplicity and utility in clinical work. It is applied from Vol. III.— 39 610 DISEASES IS AXB ABOUT THE KXEE JOIXT. the foot to the groin over a muslin or flannel bandage, fitting snugly but without constricting or exerting unequal pressure. If applied im- mediately after forcibly extending the knee under anaesthesia, the limb should be elevated for twenty-four hours and kept under observation. If the foot becomes oedematous and cyanotic, the splint should be removed, the limb padded lightly with cotton, and a new splint put on. Moderate swelling subsides usually in twenty-four to forty-eight hours. The child may then be sent home. The splint is renewed in three or Fig. 381. Fig. 382. Plaster-of-Paris splint with Lorenz' stilt. The Thomas knee-brace. (Whitman.) four and again in six to eight weeks, the child meanwhile returning for clinical treatment and provided with the necessary nourishing diet, fresh air, cleanliness, etc. The ankle should be included in the first splint; later it may be left out to prevent stiffness. If the patient is allowed to be about, v. Brims' portable splint, put on over the plaster, is very useful, as it takes the weight off the knee, the sound foot being raised by a sole and heel of the proper thickness. Lorenz obtains the same support by incorporating an iron foot-brace in the plaster. (Fig. TUBERCULOSIS OF THE KNEE JOINT. 611 381.) The two side-pieces are usually carried up to the pelvis against a thick rubber perineal ring. The splinl is then like the Thomas - j >1 int, except that it is math' immovable by the plaster and thus disencumbers the knee in walking. Many prefer the sheath splints, but their expense makes them impossible for poor patients. The author does not begin the ambulatory treatment until the second or third splint has been applied and the swelling and pain in the joint have subsided. The favorable influence of the ambulant treatment upon the general condition is greatly overestimated; ambulant treat- ment is counterindicated as long as the existence of fever, not neces- sarily high, points to florescence or, with more probability, to suppuration. The immobilization in plaster is continued till all swelling and tender- ness have disappeared, after which it is well to have a removable support- ing apparatus worn for a month or more, leaving the foot free. Such an apparatus is easily made of gauze and silicate. The resulting stiff- ness of the joint and atrophy of the muscles can be overcome gradually and often very completely if the adhesions in the joint are slight, and therefore do not require energetic treatment except massage and the wearing of an appropriate apparatus. Forcible mobilization is always liable to start up the tuberculous process. It may be years before motion is fully restored. The injection of iodoform emulsion is combined advantageously with immobilization. Although its favorable influence is not constant, the results are often striking; in hydrops the obstinate effusion may disappear rapidly and permanently. In the case of typical fungus it often pays to try the injection unless operation is urgent. Improvement occasionally follows the first injection; if none occurs after the fourth or fifth, further attempts are useless. Injection is painful, but may be done without anaesthesia. The pain usually lasts for about a day, and is occasionally followed by a greater effusion and slight temperature, both of which subside rapidly in the absence of infection. A fair-sized aspirating- needle is preferable, sterilized by boiling. The puncture is made at the outer side of the upper recess or at the appropriate point if the swelling is circumscribed. The fluid in the joint is withdrawn and 5 to 10 c.c. of 10 per cent, iodoform-glyeerin or oil is injected, according to the age of the patient, and spread through the joint by turning the needle in dif- ferent directions and then moving the joint slightly. It is not advisable to inject more than 10 c.c. at first until the toleration of the individual is determined. The wound is sealed with iodoform collodion. The injection is repeated at intervals of ten to fourteen days after aspirating; iodoform from the previous injection is often withdrawn. In suppurat- ing cases, if the action is favorable the effusion becomes more greenish and serous after the second injection. If a plaster-splint is applied immediately after injecting, a thick pad of cotton should be placed over the joint to allow for the swelling. Instead of iodoform Konig uses a 5 per cent, carbolic acid solution after washing out the joint with a 2 per cent, solution of the same. He was successful thus where iodoform had failed; to be sure, the reverse was also true. 612 DISEASES IN AND ABOUT THE KNEE-JOIST. Fig. 383. Biers congcstion-hyperosmia with or without injection of iodoform has been recommended by many recently. The rubber band is applied on the thigh for several hours or a day, according as it is well borne, and removed at night; it should only check the venous return. The skin below the bandage becomes cyanotic and swollen; the pain may be more or less severe, but soon becomes tolerable. Mikulicz cites as the special advantage of the treatment that the pain subsides rapidly in cases of very sensi- tive joints. Large abscesses are a counterin- dication; those forming during the treatment should be aspirated and injected with iodo- form. The results are very uncertain, great improvement being contrasted with failures or even exacerbation. The statistics are few. The method should be only used under con- stant observation. Partial operations, such as incision of ab- scesses, splitting of fistulas, exposure and cleansing of extra-articular osseous foci, or even free incision of cold abscesses about the joint, are less dangerous since the introduc- tion of antisepsis, and are indicated if repeated aspiration and injection of iodoform fail, or perforation outward is imminent, or the exist- ing fever is due to the cold abscess and not to the process in the joint. After free incision of the abscess the lining membrane is removed with a sharp spoon, the cavity packed with iodoform gauze, and the wound left open, in the case of large abscesses, or partially closed. Sometimes the abscesses heal entirely, then again a fistula persists for a long time. Extra- articular osseous foci are cleaned out at the same time if found. The expectations for- merly aroused by this operation were unful- filled because in the majority of cases the joint was already involved, or was opened in- The application of passive con- tentionally or otherwise at the time of opera- gestion. A, the alternate point for . , J , . ,. . „ , XT , the application of the bandage, in tion and the synoviahs infected. Neverthe- order to avoid atrophy from con- \ ess the procedure is an ideal one for foci in tore's B ' Th form two lateral flaps on each side of the incision, and readily fall to the bottom of the sac. thus lining and obliterat- ing the entire cavity. A series of interrupted absorbable sutures are now placed so as to bring the edges of the skin in contact, several of these including the floor of the sac in their bight. - close the space entirely in the middle line. The two lateral supporting sutures are tied firmly over small pads or rolls of sterile gauze, thus bringing all the interior of the sac in apposition. (Matas.) Fio. 411 . — This shows a typical sacciform aneurism with one main orifice of communication open- ing into the sac. In this type of aneurism the lumen of the parent artery is maintained. II sible in this class of cases to close the orifice of communication by suture without obliterating the lumen of the artery, and without interfering with the circulation in the main artery of the distal parts supplied by it. CMatas.) 4. Closure of the aneurismal orifices in the fusiform type of sac. In the case of fusiform aneurisms in which the continuity of the arterial wall cannot be restored, Matas recommends suture of the openings leading into the sac and obliteration of the cavity (Figs. 405, 406, and 418), POPLITEAL A.\/:rilISM. 663 after removing the clots and swabbing out the cavity with salt solution. As suture material he prefers absorbable sutures — chromicized catgut, Nos. 1, 2, •'! — although twisted, braided or floss silk, or fine kangaroo- tendon may be used; and of needles (Mayo, Kelly, Ferguson, Hagedorn ) those which are round, full curved, with long eyes and prismatic points. It is important to bring broad surfaces of the sac into apposition, so the Fig. 412. This figure is simply intended to show the same type of sacciform aneurism viewed from the posterior side. The parent artery is continuous throughout, and is simply attached to the sac at the orifice of communication. The artery has been laid open on its posterior surface, showing that the orifice of communication can be closed on the aneurismal side, without occluding the lumen of the parent artery. The drawing is taken from a pathological specimen and is utilized solely to show the favorable anatomical characteristics of this class of aneurism for the conservative procedure sug- gested by the author. (Matas.) needle should penetrate at least \ or £ of an inch beyond the margin of the orifice, and then, after reappearing at the margin, dip again into the floor of the artery and continue to the opposite margin as in the start. (Fig. 406.) Where it is necessary to close the openings quickly, the margins mav be brought together rapidly with a continued suture. In obliterating the sac Matas has found it an advantage to suture the floor between the two orifices (Fig. 406), on the Lembert plan. This raises 664 DISEASES IN AND ABOUT THE KNEE-JOINT. the floor and decreases the transverse diameter; it cannot be done if the tissues are rigid. The subsequent steps are considered later. 5. In sacciform aneurisms with a single orifice of communication haemostatic and reconstructive suture is employed with the view of pre- serving the lumen of the parent artery. (Figs. 411 and 412.) Like ma- terial and needles are used as in fusiform aneurisms, the essential being Fig. 413. Shows the same sac opened. The dotted lines indicate the position and relations of the main artery to the sac and to the orifice of communication. The object of the operation in this case is to close the orifice of communication without obliterating the main artery. The closure of the orifice with continued suture is shown in the plate. (M;itas.) to insert the suture at a sufficient distance from the usually thick and smooth margins of the opening to secure a firm and deep hold of the fibrous basal membrane, and to make the resulting lumen equal in size to that of the artery. The threads should not be in contact with the blood in the lumen of the artery. As shown in Figs. 413 and 414, it will be advantageous to begin the line of suture at some distance from the orifice, as this will secure a broader and stronger line of approximation. I'OPLITEA L . 1 M-: I A' ISM. 665 (i. Removal of the constrictor and (est of sutures. After closing all visible openings, on removing the compression the cavity should be perfectly dry. Oozing points are usually stopped by pressure or the subsequent steps. 7. Obliteration of the aneurismal sac. (Figs. 407, 408, 409, and 410.) This step of the operation is the same in all eases. If the cavity is large, Fig. 414. This shows the closure of the orifice of communication in the same type of sac with interrupted instead of continued suture. Whether the continued or the interrupted suture be used (the former being preferred by the author) it is important to begin the suture line at some distance from the orifice, so as to infold a considerable surface of the sac at the start; then care must be exercised to insert the sutures so as to grasp a considerable surface of the margin, in a manner that the point of the needle shall penetrate the entire thickness of the margin, and yet not so far within the lumen of the artery as to encroach upon the calibre or to leave the suture material in contact with the blood current. When the sutures are tightened they should bring the marginal surfaces in broad appo- sition without projecting into the anterior portion of the artery or encroaching excessively upon the lumen of the vessel. (Matas.) it is well to reinforce the first row of sutures by a second row, applied on the Lembert plan on a higher level. The remaining space is then closed by turning in the skin-flaps, which are held down by one or two relaxation sutures applied on each side of the median line with a large-sized full- curved intestinal needle, grasping a considerable portion of the sac in its 666 DISEASES IN AND ABOUT THE KNEE-JOINT. Fig. 415. Fig. 416. Sectional diagram showing method of obliterating the aneurisma! sac in the fusiform type of aneurism with two open- ings. In this class of cases (Figs. 405 and 406) the tunics of the parent artery blend with the sac, and the arterial cavity cannot usually be restored. The dia- gram shows the first row of sutures (I) which obliterates the orifice of the artery at the bottom of the sac. The second row of sutures is shown higher up (II) and also the effect of this- row in reducing the capacity of the sac. The obliteration of the remaining part of the cavity by the folding in or inversion of the sac walls, with the attached over- lying skin, is shown in III. The function of the deep sutures (IV) tied over gauze pads, and of the more superficial skin sutures (V), in obtaining firm contact of the opposed surfaces, is also shown. Thisdrawing ispurelyschematic; it gives an exaggerated idea of the size of the sac walls, and is chiefly intended to give an idea of the position of the sutures and other parts. (Matas.) Shows a possible but not yet tried method of restoring the large lumen of the parent artery in favorable cases of fusiform aneurism with two opening- in which the healthy and flexible character of the sac will permit of the restoration of the arterial channel by lifting two lateral folds of the sac and bringing them together by suture over a soft rubber guide. The prin- ciple of this operation is pre- cisely like that adopted in a Witzel gastrostomy. The figure shows the soft-rubber catheter lying on the floor of the sac and inserted in the two orifices of communication. The sutures are placed while the catheter is in position acting as a guide. (Matas.) PLATE XVII Aneurism of the Popliteal Artery. (Jacob.) POP LITE A L A A7-; / 7/ ISM. 667 bight. The needle should penetrate the entire thickness of the sac; by carrying it through in this way a loop is formed, the ends of which are carried through the skin-Haps by transfixation with a straight Reverdin needle, and tied firmly over a loose pad of gauze after the flaps have been carefully adjusted in position. (Figs. 40N, 409, and 410.) A few interrupted catgut skin sutures complete the operation. (Fig. 410.) ' Fig. 417. This shows a more advanced step of the procedure described in Fig. 416. The sutures are nearly all tied, and the new channel is completed except in the centre. The two middle sutures are hooked and pulled out of the way while still in position, and the catheter is withdrawn. The obliteration of the sac and final steps of the operation are carried out precisely as described in Figs. 407, 40S, 409, and 410. (.Matasj As no exposed or raw surfaces are left in view, there is no need for drainage, and union per primam can be confidently expected. A simple sterile gauze dressing is applied as a graduated compress to fill the hollow left in the place previously occupied by the aneurism, and held in position by a few strips of aseptic rubber plaster. A thick layer of cotton-batting envelops the limb from periphery to trunk. Immobilization is secured by means of a well-padded splint, or starch, or plaster-of-Paris roll bandage. If there are no reasons to the con- 668 DISEASES IN AND ABOUT THE KNEE-JOINT. trary, the first dressing should not be disturbed for a period of a week or ten days. It is to be regretted that the original article of Matas from which the above description has been freely derived cannot be given more in Fig. 418. LeftErachial. Ligature. v/vm. Inf P/r, 'aru\^~ /Jlnar RaZ]//>L This is a reproduction of a diagram published in the Medical News (Philadelphia). October 27, 1SS8. It is intended to explain the condition found in a case of traumatic aneurism in which Dr. Matas applied intravascular arteriorrhaphy for the first time. The abundance of the collateral supply in that case could only be accounted for by a distribution of the vessels such as shown in this figure. The failure of the ligatures applied to the main artery above and below the sac and dif- ficulties of extirpation were well illustrated in this case, and led to the suture of the aneurismal orifices, which promptly secured their obliteration and an immediate arrest of the hemorrhage. (Matas.) detail. The reader is therefore urgently recommended to consult the same, which is regarded as "one of the most important of the recent contributions to surgery."] MALFORMATIONS, INJURIES, AND DISEASES OF THE LEG. CHAPTER XXXII. MALFORMATIONS OF THE LEO. Total defect of the foot or leg is of slight practical interest to the sur- geon. The stump, often small, consists of skin and fat, and occasionally has appendages covered by a nail which remind one of rudimentary toes. The anomalies are due partly to faulty construction, partly to constriction by amniotic bands. In the latter case there are sometimes one or more deep circular constrictions on the leg which may extend down to the bone. The parts below the constriction, if it is slight, may be almost normal; in other instances they are atrophic and show anom- alies in development and position. Defects of single bones of the leg are more important; they may be partial or complete. Defect of the fibula is more frequent than that of the tibia : if partial of the fibula, it is usually the upper portion that is lacking; of the tibia, the lower portion. With defect of the fibula are usually associated an absence of one or more toes and a characteristic anomalous position of the foot in ever- sion as in flat-foot ; the foot may even lie against the outer side of the leg. The tibia may be normal; but the talocrural joint is more or less subluxated. In other instances the tibia is curved, most frequently in the lower third with the convexity inward. (Fig. 419.) This curvature is referred by many to intra-uterine fracture. With defect of the tibia the knee-joint, which is usually intact in con- nection with defect of the fibula, is more or less changed as a rule, and always changed with total defect. The fibula is dislocated backward and articulates loosely with the outer condyle of the femur. The leg is flexed, adducted, atrophic, and the entire limb undeveloped. The fibula is always curved, usually convex forward; the foot is strongly adducted. As the deformities increase the longer the limb is disused, it is important to correct the same as soon and as far as possible and to make the limb useful by means of a supporting apparatus. According to the degree of curvature and the age of the patient manual correction, osteotomy, resection of the joint, or arthrodesis of the knee or ankle, or of both, are to be considered. Recently the joint has been stiffened successfully, in the case of the ankle, by Bardenheuer with the modifica- tion of splitting the tibia and inserting the astragalus in the fork thus formed. In view of the shortening of the limb it is often advisable to anky- lose the foot in a pes equinus position and not at a right angle to the leg. ( 669) 670 MALFORMATIONS OF THE LEG, The so-called intrauterine fractures of the leg (Fig. 420) belong here more properly, as it is still uncertain whether they are always fractures. Fractures of the bones of the extremities in utero from external violence, although rare, are unquestionable; they usually heal by callus with displacement, but may give rise to a pseudarthrosis. The same name has been applied to congenital curvatures of the bones of the leg in which the most careful histological examination has shown no trace of previous separation of continuity or callus. These curvatures, which, as stated, are frequent in the tibia in connection with defects of the fibula, also occur simultaneously in both bones of the Fig. 419. Fig. 420. Defect of the fibula and one toe in addition to a so- called intrauterine fracture of the tibia. (Reichel.) Intrauterine fracture of the leg in a child four years old. leg; as a rule they are located at or below the junction of the lower and middle third; the convexity is directed forward. The skin at the summit of the curve of the tibia often shows a small white cicatricial spot, slightly depressed, to which a piece of amnion is attached; this would seem to indicate that the curvature was caused by the pressure of an unduly small amniotic sac or that it is due to amniotic adhesions and bands acting at an earlier period. The curved bones are thinner than in the other normal limb and like the overlying soft parts remain some- what atrophic in the further development. The flexed position of the foot gradually increases as the limb is used. The prognosis is unfavorable as there is little tendency to formation of bone at the point of curvature with or without operation, hence there is often insufficient callus formation and pseudarthrosis. (Fig. 420.) CHAPTER XXXIII. INJURIES OF THE LEG. FRACTURE OF THE SHAFT OF THE BONES OF THE LEG. Next to fractures of the forearm, those of the leg are most common, according to v. Bruns 16 per cent, of all fractures. They occur at any age, even in utero and intrapartum, but are far more frequent in well- developed adults, and in men than in women. This is easily explained by the conditions always connected with hard labor. Direct fractures are more frequent than the indirect, the common causes being blows from heavy falling bodies, run-over accidents, hoof-blows, etc. Indirect frac- ture is caused by falling upon the feet from a height (compression) or by accidents with the foot held fast (inflexion or torsion or both). Also in the cases due to direct violence the fracture is exceptionally produced by compression, but usually by bending, in the same way that a stick, held at both ends, is broken by a blow against the middle. On account of the thickness of the head of the tibia and the prominence of the malleoli and heel, it rarely happens that the shaft is supported in its entire length, even in the case of run-over accidents. In not a few of the indi- rect fractures there is a combined torsion and bending action, as in fall- ing from the effects of a blow with the foot fixed. Inflexion fractures are rare. 1 As it is the tibia that actually supports the body, it is clear that at the moment of fracture the fibula cannot alone withstand the weight of the body and so breaks, hence the frequency of fracture of both bones. The site of fracture is usually at the junction of the lower and middle third. Direct fractures occur at any point according to the place at which the violence is applied. In the upper, stronger third, however, they can only result from very great violence. The fibula usually breaks a trifle higher than the tibia. Double fractures are not common; in fracture by bending a wedge is often broken off, its base correspond- ing to the concavity of the curve. The line of fracture, in spite of the great frequency of direct violence, is transverse in only a small number of cases, as the surgeon is usually dealing with a fracture by bending; the surfaces are serrated, the inter- locking of the teeth preventing any great displacement. (Fig- 421.) Commonly the line is oblique, generally from above and behind, down- 1 From the above it will be seen that the author distinguishes of the fractures due to violence applied against the shaft : those in which the ends of the shaft are fixed while the force is applied somewhere between the two ends (fracture by bowing), and those in which one end and part of the shaft are fixed while the force "snaps off" the bone somewhere beyond these points of sup- port (fracture by inflexion). (671) 672 INJURIES OF THE LEG. ward and forward, although not infrequently in the reverse direction. This characteristic, so-called "flute mouth-piece form" (Flotenschnabel- form) of the fragments is liable to cause impalement or perforation of the soft parts. (Fig. 422. ) The wedge-shaped fragment of the frac- ture by bowing is not infrequently broken into several pieces. Spiral fracture by torsion (fract. en V, Gosselin; fraet. en coin or cuneenne, Fig 421. Fig. 422. Serrated transverse fracture of the shaft of tibia and fibula in a boy. (v. Bruns.) Very oblique ("clarinet mouth-pipce" I fracture of tibia and double fracture of fibula, (v. Bruns.) Larrey) is rather common, according to v. Bruns more frequent in the lower half of the tibia than in any other bone. A fissure not infre- quently runs from the re-entrant hollow angle of one or both fragments into the adjacent joint, sometimes in the continuation of the spiral, sometimes in a line joining its ends. (Figs. 423 and 424. | The severity of the direct violence explains the frequency of comminution, of multiple fractures, and of splintering of the entire shaft. (Fig. 425.) Lauen- FRACTURE OF THE SHAFT OF THE BONES OF THE LEG. 673 stein calls attention to an apparently typical injury, avulsion of a plate of hone- from the anterior surface of the lower end of the tibia; the base of the fragment is below, and is held by the anterior pari of the capsule of the ankle-joint ; above, this fragment tapers to a point or ends more bluntly. In the I cases seen by him the fracture was due to a fall from a height, and was always complicated by other injuries of the leg. Fig. 423. Fig. 424. Fig. 42.i. Fig. 423. — Spiral fracture of the leg. (v. Brans.) Fig. 424. — Spiral fracture of the tibia with fissure into the ankle-joint, posterior view. (v. Brans.) Fig. 42.5 — Extensive comminution of both bones of the leg due to run-over accident, (v. Brans.) A considerable number of the fractures are compound; in indirect fractures usually from perforation of the soft parts by a sharp frag- ment, but with very little laceration of the tissues; the soft parts may become interposed between the fragments and necessitate incision to effect reduction. Or a subcutaneous fracture may become compound secondarily by pressure-necrosis of the skin. In direct compound Vol. III.— 43 <37-± INJURIES OF THE LEG. fractures the skin is generally broken by the trauma and the deeper tissues more or less contused and necrosed. The size of the skin-wound does not denote the amount of damage to the muscles or bone; the wound may be large and the bone only fractured obliquely or trans- versely at one spot, or it may be small and yet the bone be splintered severely and the muscles torn or crushed. In severe cases in which the wound extends down to the fracture the large vessels and nerves may be contused. In contrast to a simple fracture which has perforated the skin and which may be regarded as aseptic if recent, compound fractures due to direct violence are often soiled by dirt, pieces of clothing, etc., and so must be regarded and treated as infected. In gunshot fractures, especially those made by the modern small- calibre weapons, although the wound of the soft parts is slight, the tibia is very apt to be severely splintered; fissures usually extend into one or both adjacent joints. Round-hole penetrating gunshot wounds are seen almost exclusively in the spongiosa of the head of the tibia. Displacement of the fragments may be absent in transverse fractures, but is common in oblique fractures; the nature of the displacement depending largely on the line of fracture. Usually the lower fragment is displaced outward, backward, and upward; occasionally forward and inward. With this lateral displacement are usually combined shortening, axial inflexion at an obtuse angle opening backward, and outward rotation of the foot. In double fractures the nature of the dis- placement may vary greatly. If the fragments are much separated, the muscles easily become interposed and impaled. Diagnosis. — The deformity due to displacement and shortening in the majority of cases gives the diagnosis at a glance; if not pronounced, it is increased by the effort to lift the leg. The superficial situation of the anterior border and surface of the tibia permits of accurate palpa- tion and the detection of even slight irregularities along the bone, espe- cially in recent injuries. In a few hours, or even sooner, palpation is hindered by the pain and swelling; by carefully pitting the swelling with the fingers the contour of the tibia can almost always be felt. The examination for fracture therefore should always begin with this harm- less and least painful manipulation. If this is not conclusive, false motion and crepitus may be elicited by seizing the leg above and below the point of tenderness and shifting the fragments; usually both these symptoms are very distinct except with impaction; crepitus may be prevented by interposition of the soft parts, but false motion is then pronounced, and bony crepitus can be felt on overcoming the inter- position. The line of fracture may be determined by simple palpation alone or by shifting the fragments upon each other. If the latter is necessary, it is always better to decide first whether anaesthesia is required for reduction, and to avoid further painful manipulation until treatment is instituted. In the absence of any displacement anaesthesia is unneces- sary; the characteristic localized point of tenderness then becomes very significant, and a fracture may be assumed and the treatment made to correspond. FRACTURE OF THE SHAFT OF THE BONES OF THE LEG. 675 Prognosis. — Simple fractures heal by bony union in children in about three or four weeks; in adults in six to eight weeks. Consolidation is proportional to the accuracy of coaptation and immobilization. Any great displacement persisting may mean consolidation delayed for many weeks or even pseudarthrosis. Delayed union is sometimes seen without apparent local or constitutional cause; but these cases are rare. Bony union between the tibia and fibula is occasionally observed, generally as the result of unreduced displacement. Union without some displacement, except where there is no tendency to such, is rare, as shown more recently by the x-ray. Slight lateral displacement and overlapping of the lower fragment, corresponding to the obliquity of the surfaces, some axial deviation with prominence of the tip of the upper fragment, or inversely backward curvature of the leg with the concavity forward, are of rather frequent occurrence; the same applies to the persistence of a certain amount of inward or outward rotation of the lower fragment. Even greater displacement and shortening can usually be prevented and overcome if properly treated. The functional disturbance, as a rule proportional to the amount of displacement, is fortunately less in fractures of the leg than one would suppose from the x-ray pictures. With firm union, a movable joint, and not too much displacement, the limb becomes strong with use, although the patient may complain for years — especially as long as an indemnity can be claimed — of indefinite pains in the limb, particularly with weather-changes. Even in the case of uneventful recovery without displacement a certain amount of stiff- ness persists in the ankle- and knee-joint from immobilization, so that the full working-ability is rarely recovered before three months, often not before six months or a year or longer. The stiffness is less than that following fractures of the ankle, except in the case of fissures extending to the joint and producing ha?marthrosis, or in older individ- uals with arteriosclerosis, cardiac weakness, oedema due to circulatory disturbances, or a tendency to arthritic processes. Compound fractures with small skin-wounds, especially those due to outward perforation, if kept aseptic, often heal in the same manner and time as simple fractures. Generally more time should be allowed for recovery, however, in spite of the fact that union is frequently better than in simple fractures with persisting displacement. The prevention of infec- tion and phlegmon, the first essential of treatment, often requires a dress- ing too large to insure the exact immobilization obtainable in simple fractures. Further, the frequently severe damage of the deeper soft parts, especially the muscles, is always accompanied by a certain amount of adhesion and cicatricial tissue formation which hinders restoration of the normal function, the more so as the wound prevents early massage. All these conditions are made more unfavorable by any necessary extensive incisions or packing, and especially by suppuration, phlegmon, or necrosis of splinters or of the fracture-ends. Although antisepsis has fortunately made it possible as a rule to save the life and limb of the patient, still 676 INJURIES OF THE LEG. Fig. 426. at times, in spite of careful treatment, the surgeon is compelled to resort to secondary incisions, resection, or amputation. The prognosis of compound fractures, even with small skin-wounds, is always more serious than that of simple fractures, and the functional result is generally less satisfactory. The author cannot subscribe unre- servedly to the statement in a well-known text-book that " the compound fractures of the leg formerly so dreaded on account of suppuration, necrosis, and pyaemia recover uneventfully under antiseptic precautions." The unfavorable prognosis which obtains in reference to intrapartum fractures of the leg is based upon the fact that pseudarthrosis with tapering of the fragments and considerable shortening have been seen in not a few instances. These unfortunate sequelae are due partly to non-recognition of the injury at the proper time and the consequent improper treatment, partly to confusion with the so-called intrauterine fractures (congenital curvature). (See page 670.) If recognized in time and treated properly from the outset, an intrapartum fracture usually heals as well as one sustained later in childhood. Treatment. — The danger of the thin skin be- ing perforated by a sharp fragment and a simple fracture thus becoming compound, urges the greatest care in transporting and undressing the patient ; tight-fitting clothing should be ripped open and the shoe cut open up the side and not pulled off forcibly. As a rule the sooner reduction is effected the more easily and certainly coaptation can be obtained. In cases of marked displacement and muscular contraction hindering reduction — for example, in oblique fractures in well-developed laborers — anaesthesia is advisable. It is usually stated that the foot is straight if the prolongation of the inner border of the patella passes between the first and second toes or if the line joining the anterior-superior spine and the first meta- tarsal touches the inner border of the patella. The author does not attach too great value to this statement as gauging by the eye alone may be deceptive; it appears more important to compare carefully the con- tour with that of the sound limb. If reliable assistance is lacking — even the strength of the best of helpers is often unavailing or gives out too quickly — especially if anaes- thesia is contraindicated, Baudens' extension method, as modified and described recently by Kolaczek, is valuable to maintain uniform traction during the application of the plaster-splint. A perineal sling is attached to the head-post of the bed; a piece of wood the length and breadth of the foot, having a loop of sail-cloth about 3 feet long laid between it Vulpius' aluminum splint, with sliding sections and flexible rod. FRACTURE OF THE SHAFT OF THE BONES OF THE LEU. 677 and the foot, is bandaged to the sole of the foot and the ends of the sailcloth tied to a double rope, the latter being fastened to the door- handle or other fixture and tightened by twisting. The foot is supported and the traction increased till the shortening is overcome. After the plaster-splint has hardened the extension is removed. The simpler fixation apparatus of wood, tin, wire, straw matting, etc., used for transportation and fixation during the first few days, should be removed as soon as the conditions permit of accurate correction and immobilization. The requisites of a rational method are only met by continuous extension, or the plaster-of-Paris splint, both of which give satisfactory results. Continuous extension, as recommended especially by Bardenhener and his school, to be effectual requires, according to Wolff, strict observance of the following directions: 1. Application as early as possible. 2. The adhesive plaster strips should extend well Fig. 427. v. Volkmann's splint for the leg. (Stimson.) above the fracture, in very oblique fractures to the middle of the thigh. 3. The plaster strips should be applied closely at the ankle with the malleoli padded, not separated by a spreader. 4. In very oblique frac- tures 30 to 40 pounds may be insufficient and even 60 or 70 be required. 5. The lower fragment, displaced backward, may be drawn forward by vertical traction of about fO pounds with counterpressure by means of a 20-pound sand-bag or Bardenheuer's loop upon the upper fragment. The constant supervision required by the extension splint usually makes the typical plaster-splint preferable for private practice. It is also the one most used in hospitals, and, properly applied, gives excellent results. The severe circulatory disturbance or even gangrene which has occasionally resulted from applying a plaster-splint too soon or too tightly, has led the majority of surgeons to advise preliminary immobili- zation in a Volkmann T-splint (Fig. 427), or v. Brims' position splint .;:> INJURIES OF THE LEO. (p. 543), or a wire-splint, the plaster-splint being applied at the end of six or eight days, after the swelling has subsided. The following points speak for early or immediate immobilization in plaster: 1. The more recent the fracture the easier and more complete the reduction. 2. Fixa- tion in a tin- or wire-splint does not prevent the displacement due to muscular contraction in the first few days, so that anaesthesia and further reduction are necessary in applying the plaster-splint. Accurate palpa- tion of the fragments is also hindered by the swelling, hence the control of reduction is less certain. 3. The earlier the immobilization the sooner the discomfort ceases, especially the pain caused by muscular contraction due to rubbing together of the fragments. If the correction is good and the splint is properly applied, the patient is usually free from pain and remains so after the plaster hardens. 4. After early immobilization the swelling is generally slight, as the hemorrhage due to movements of the fragments ceases. The danger of circulatory disturbance, which Fig. 428. Beely's plaster-of-Paris strip splint with suspension rings for fracture of the leg. should not be underestimated, is prevented by padding the limb thinly with cotton and a soft flannel bandage and applying the plaster-splint loosely or, better, by using instead a Beely plaster-of-Paris strip-splint. The splint, whether strip or circular, should immobilize the ankle and knee, extending from the toes to the middle of the thigh. The limb should be elevated for the first two or three days upon pillows or by suspension. 'Fig. 42Vi If the toes become blue, cold, numb, and swollen, the splint must be removed under all circumstances; hence careful oversight is indispensable during the first few flays. It is well to remove the splint in six to eight days for inspection, to correct any existing deformity and to apply a tighter splint to meet the subsi- dence of the swelling. Later the splint is renewed at intervals of two or three weeks, the limb is massaged while traction is maintained upon the foot, and the knee and ankle-joint are moved passively at the latest after the second change of splint. As soon as the callus is firm, not necessarilv entirelv ossified, namelv, after the fifth week, the author FTiAcrrni: of the shaft of the iiosf.s of the leg. g79 allows the patient to go about in a plaster-splint till union is complete; if complete bony union is delayed, a removable silicate-splint may be worn extending above the knee, and massage and passive motion applied every time it is removed. Recently ambulant treatment, a circular plaster-splint being worn, has been preferred by many surgeons by reason of the warm rec< m- mendation of Krause, Bardeleben, Albers, and others. After the swelling has disappeared, on about the eighth day, the splint is applied directly upon the shaven or greased skin. v. Brims' portable splint is also used over a light plaster-splint. (Fig. 354, p. 544.) The author must admit openly that so far he has not been able to convince himself of the much praised advantages of this method, and therefore can only recommend it for cases in which longer rest in bed would be dangerous on account of existing diseases of the circulatory or respiratory organs. There is also the possibility of recurrence of slight displacement by this method. In the absence of the above contraindications he regards the recumbent treatment as insuring the best results. In the rare cases in which in Fig. 429. Fenestrated plaster dressing. (Stimson.) spite of all care the reduction was only partial or the interposition of soft parts or their impalement could not be overcome without operation, in recent years an incision has been made and the fragments sutured in place with excellent results. As this makes the greatest demands upon asepsis, it is adapted for use only in well-appointed clinics and hospitals, and should be limited to exceptional cases. Compound fractures make greater claims upon the care and technical ability of the surgeon. Recent fractures which have perforated and made only a small skin-wound may usually be regarded as aseptic; the wound may be packed temporarily with sterile or iodoform gauze while the skin is carefully cleaned and sterilized from the foot to the thigh; the blood is squeezed out of the wound and the latter closed with an aseptic dressing. If the wound is very small, it may be covered with iodoform or sterile gauze, a plaster-splint can be applied over it, and the case treated like a simple fracture. If infection is suspected, the wound is widened sufficiently to expose the infected parts, especially the fragments, all blood-clots and loose (380 IXJUBIES OF THE LEG. splinters are removed, the wound cleansed, soiled or badly contused tissues are excised and the cavity drained, or, better, packed with iodoform gauze. If infection of the surfaces of the fragments is suspected it may be necessary to lay gauze between the fragments; naturally they have to be coaptated later. If the surfaces are believed to be clean, they should be apposed and fixed by suturing or screwing the fragments together; the wound is drained or packed down to and about the frag- ments. A thick antiseptic dressing then envelops the limb; for this purpose "moss-pads" can be used with advantage as they fix the fragments well. The limb is then bandaged in a Volkmann T-splint or wire-splint. If only a slight amount of discharge is anticipated the author generally applies a plaster splint over the dressing to be left on eight or ten days. The case should be watched carefully and the temperature taken regularly. If there is no fever, if the wound is clean, and the discharge slight, the drains or packing can soon be omitted and the dressing made smaller and a plaster-splint applied. Otherwise the wound must be kept open and any infection treated on general principles. The tendency to displacement should be combated as much as possible, but generally cannot be entirely prevented. Later, the removal of necrotic splinters or resection of the fracture ends to give better coaptation has to be considered. Amputation or exarticulation is not nor ever will be entirely dis- pensable in cases of severe contusion and laceration of the leg, especially of the soft parts and large vessels. General rules cannot be given as to the indications for these operations in such injuries. Such procedures will be limited or extended according to personal experience and skill and the conditions under which treatment has to be conducted. Asepsis enables us at the present time to greatly extend the application of con- servative measures in the treatment of gunshot fractures with small skin wounds. FRACTURES OF THE TIBIA OR FIBULA. Fracture of the tibia or fibula alone is not frequent; according to v. Bruns it represents only 2 per cent, of all fractures. Fracture of the shaft of the tibia alone is rare, because the fibula is not able to bear the weight of the body at the moment of fracture, and so breaks. W nat has been said in discussing fractures of both bones applies to fractures of the tibia, except that any displacement is slight or absent and no deformity is produced by lifting the leg, as the fibula acts as a sort of splint. Exceptionally there are marked lateral displace- ment and inflexion due to continuation of the direct violence; under certain circumstances the reduction of such a displacement may be very difficult. Usually there is immediate complete loss of function; excep- tionally in the case of transverse fractures with interlocked serrations the patient may be able to walk a few steps if the pain can be endured. The treatment is aided bv the integrity of the fibula. DISLOCATION OF THE FIBULA. 681 Fractures of the fibula in the middle third arc caused almost exclu- sively by direct violence, run almost transversely, and have little tendency to displacement on account of the thick muscular covering and the splint action of the tibia. For the same reason it is often difficult to elicit typical symptoms of fracture, the diagnosis depending, aside from the nature of the violence, chiefly upon the fracture pain. One spot is always particularly tender on pressure, and pain is produced by pressing both bones together at a distance from the point of injury; this is due to the rubbing of the surfaces upon each other and crepitus, although slight, can often be obtained. If the pain can be borne, walking is usually possible. The fracture unites in four or five weeks under any kind of retention splint. At the upper end of the fibula fractures are caused, aside from direct violence, by muscular traction; for example, one sees numerous instances of fracture of the head of the fibula due to violent contraction of the biceps; as a rule this action is associated with simultaneous forcible adduction of the leg, due to direct violence. The fracture is interesting chiefly on account of the associated injury of the peroneal nerve, which passes forward around the neck of the fibula. The nerve may be torn, transfixed, or contused by the fragments or enclosed and constricted later by callus. The head of the fibula projects outward unduly, is drawn up during active flexion of the knee by the biceps and sinks back during extension; below it can be felt a depression and in this the upper end of the shaft. After reducing the fragments the limb can be put up in almost any splint which will hold the knee slightly flexed. Partial or complete paralysis of the peroneal nerve indicates the use of electricity, massage, and baths; if these fail to act, the nerve should be exposed and sutured, or freed from any constricting cicatrix or callus. In the lower third the fibula breaks separately at a characteristic point 2 to 2\ inches above the outer malleolus, or in connection with dislo- cation or sprain of the ankle-joint, or from direct violence. The frag- ments are usually displaced more or less ad axin, forming an obtuse angle opening outward. The foot is slightly everted (flat-foot position). The treatment will be considered under injuries of the ankle-joint. DISLOCATION OF THE FIBULA. Of total upward dislocation of the fibula, namely, in both joints, 3 cases have been published in the literature by Roger, Stromeyer, and Sorbets. They were caused by violence acting from below upon the outer edge of the foot. Dislocation at the upper tibiofibular joint has been often seen as the result of disturbances in growth following acute osteomyelitis. If the growth of the tibia is checked, the head of the fibula advances upward; the reverse follows if the growth of the fibula is retarded or that of the tibia increased. Looseness of the joint and displacement backward or forward follows inflammatory processes 682 INJURIES OF THE LEG. rather often, especially chronic serous inflammation of the tibiofibular joint transmitted from the knee. Traumatic dislocation of this joint is very rare. Hirschberg saw 10 cases of this sort, dislocated upward with simultaneous oblique fracture of the upper third of the tibia, but only 2 with fracture of the fibula below the head. Nine cases of forward dislocation of the head and 4 of backward dislocation without fracture have been reported; the dislo- cation forward was only once due to direct violence, in the other instances it was the result of falling or slipping, the patient forcibly contracting the muscles arising from the front of the fibula, the extensor communis digitorum, extensor hallucis longus, and the peronei, to check the fall. Simple backward dislocation is referred chiefly to the traction of the biceps. In forward dislocation the limb is held extended, the foot adducted; the patient cannot stand but can move the leg while sitting. In the region of the peroneal nerve tingling and numbness are present. At the outer side of the tibial spine the dislocated head can be seen and felt projecting abnormally with the biceps tendon curving forward to it. In backward dislocation the limb is held flexed and the head of the fibula can be felt and moved behind its normal position. Reduc- tion is essentially by direct pressure. Retention requires fixation for two or three weeks in a splint, in the case of backward dislocation preferably with the knee slightly flexed to relieve the traction of the biceps. Dislocation at the lower tibiofibular joint without other injuries is very doubtful; its occurrence with fracture and dislocation of the ankle will be discussed later. PSEUDARTHROSES OF THE LEG. Pseudarthrosis from fracture is seen chiefly after intra-uterine, intra- partum fractures or those occurring in early childhood In adults it may be the sequel of very oblique fractures, of marked displacement (Fig. 430), of interposition of the soft parts, and especially of compound comminuted fractures in which large splinters are free or are thrown off later as the result of suppuration. It not infrequently follows necrosis of the tibia due to osteomyelitis, either on account of insufficient bone production after necessarily early removal of a sequestrum or as the result of destruction of the new bone by suppuration. The mobility of the false joint varies according to the amount of bone destroyed and the tapering of the fragments, which in children is often very pro- nounced. If due merely to delayed union in connection with only moderate displacement, recovery is usually possible in adults — although perhaps requiring months — by the use of conservative measures — namely, by the wearing of a portable well-fitting plaster- or silicate-splint; by Bier's VSEU1) ARTHROSES OF THE LEG. 683 Fig. 430. congestion-hyperaemia, the tourniquet being applied about the thigh | Dumreicher, Helferich); by massage, painting energetically with iodine, or injecting a few drops of tincture of iodine, or alcohol, or lactic acid into the callus. Operation is to be considered for older pseudoarthroses in young chil- dren, for large defects of bone, and those cases in which the above treat- ment fails. The pseudarthrosis is ex- posed, the fibrous tissue between the stumps excised, the latter freshened up transversely, or rabbeted and fastened together with sutures or screws. Even after careful operation the prognosis is unfortunately often made unfavor- able by lack of growth of the perios- teum. The operation then has to be repeated or irritants tried. If the intact fibula prevents the approxima- tion of the stumps of the tibia wheie the defect is large, it may be neces- sary to excise part of the fibula ; on account of the resulting shortening it is better, however, to do a plastic operation. Halm transplanted the upper end of the tibia upon the lower stump of the divided fibula with suc- cess. Poirier recently reported a sim- ilar case ; with the .r-ray he watched the implanted fibula, stimulated by use, grow to two-thirds the size of the tibia in three years. In appropriate eases the defect may be filled in by the Konig-Miiller method of implanting a flap of skin, periosteum, and bone from one or both fragments ; it has been successful in many in- stances.. If all other means fail, a supporting apparatus must be worn or amputation be performed. Pseudarthrosis of the leg. (v. Bruns.) CHAPTER XXXIV. DISEASES OF THE LEG. INFLAMMATORY PROCESSES AND ULCERS OF THE SOFT PARTS. Furuncle of the skin on the hairy parts of the leg, inflammation of the skin and subcutis around small infected contused wounds, abrasions, scratches, etc., are extremely frequent affections, and lymphangitis and erysipelas are not uncommon after such lesions. Deep phlegmon may be due to suppuration in the foot which is transmitted upward along the tendon sheaths or lymphatics; it is also seen as a local manifestation of infected compound fractures, purulent periostitis or osteomyelitis of the bones of the leg, and occasionally it occurs primarily as a periphlebitis about thrombosed and suppurating varicosities. In the latter case the avenue of infection, whether solely through the blood or not, can seldom be determined. All these inflammations have nothing uncommon about them, and are treated on general principles. But they have one peculiarity, namely, that the circulation in the leg in the vertical position is less favorable to recovery; so it happens that in the absence of pain the patient often cannot be kept in bed, and a slight and insignificant injury remains unhealed and thus gives rise to the production of chronic ulcers. Of the chronic inflammations, two especially claim the surgeon's interest, chronic eczema and ulcer, the latter the cross of all hospitals, and ill-famed from past ages on account of its frequency and obstinacy. The common cause of their frequency lies in the unfavorable local con- ditions of the circulation and improper care and lack of cleanliness. The circulatory disturbance produced by varicosities is responsible for the fact that the above conditions are found so frequently, in about half the cases, with varicose veins. A slight abrasion of the skin from a blow, the chafing of a boot or scratching, etc., combined with uncleanli- ness, leads to the development of a slight superficial inflammation of the surrounding skin which heals over finally with a delicate eschar; the latter, especially if situated over the anterior border of the tibia or adherent to it, is easily injured, infected, and becomes ulcerated; if the process is repeated at intervals, an ulcer is formed with thick infiltrated base and walls and little tendency to heal, the putrefying pus producing a simple papular or vesicular eczema of the surrounding skin; in other instances the eczema is primary, and is irritated and infected by scratch- ing and so leads to the formation secondarily of an ulcer. Or the ulcer may be due to rupture, or inflammation and perforation of a thrombosed varicose vein ; also to a fistula from a sequestrum caused by osteomye- litis. ( 084 ) INFLAMMATORY PROCESSES AND ULCERS OF SOFT PARTS. 685 Fig. 431. In spite of the manifold causes the further development of the ulcer is usually uniform in all cases. With proper and sufficient treat- ment recovery is possible; but the unfavorable social relations, the ignorance and carelessness of the patients, most of whom belong to the laboring classes, often prevent successful treatment. Before the cicatrix is solid or even complete it is exposed to the same injurious influences, and the result is an acute exacerbation and gradual steady advance of the process. The recurring inflammation, the consequent thrombosis of the lymphatics, the congestion due to the varicose veins all lead to an advancing plastic infiltration of the soft parts, not only a serous inflammation, but a cellular deposit, a new growth of connective tissue with dense thickening of the skin and subcutis, the latter becoming adherent to the muscles, tendons, and even the bone, and the irritation penetrating deeper causes chronic inflamma- tion in the tendon-sheaths, periosteum, and joints, adhesions between the tendons and their sheaths, the formation of periosteal exostoses, and stiffness of the joint. The muscles often atrophy at an early date, partly as the result of the circulatory disturbance, partly of in- flammation and of disuse. Flat-foot is there- fore a frequent result ; exceptionally an inflam- matory contracture can lead to the development of a club-foot. The ulcer is commonly situated in the lower third or at the junction of the lower and middle third of the leg, although its seat, size, and form may vary greatly. It is often found over or behind one of the malleoli, a spot the size of a lentil, insignificant but extremely stubborn, the edges irregular and red, the surrounding skin bluish-red and filled with a thick network of fine varicose veins. This form is often very painful. In other cases one or more flabby, granulating spots from f to 1 inch in diameter, are situated over the front surface of the tibia and extend down to the bone, the irregular edges being ulcerated, the surrounding skin indurated, immovable, red- dish-brown or brown in spots, often warty, covered with thick scales; the base of the ulcer is covered with flabby discolored granulations secreting a thin, foul-smelling pus. In still other instances the ulcer encircles the leg; below it the foot and leg are then more or less thickened as in elephantiasis, and with the stiffened ankle-joint serve to form a sort of "living stilt." (Fig. 431.) Chronic eczema of the leg, with or without ulcer, is apt to be of the Circular ulcer of the leg. with elephantiasis of the foot. (v. Bruns.) 686 DISEASES OF THE LEG. squamous variety; the hypertrophic superficial epithelium may come off in small dry scales, or the skin is of a bluish-red or brownish color and casts off large scales or crusts which, glued to the epithelium by the secretion, are easily picked off, exposing the reddened, moist, and glisten- ing corium beneath. Syphilitic ulcers are not rare on the leg and are important. In some instances the surgeon is dealing with a secondary eruption, in others with a degenerated gumma, the latter often from the periosteum of the tibia. The ulcers have the characteristic specific appearance, the sharp-cut edges and bacon-like membrane, and are usually easily recognized as syphilitic. Their specific nature is also often indicated by their being situated on the upper part of the leg, occasionally on the calf, while the lower part of the leg is free, although the common ulcer occurs here also, but rarely. As a rule they heal rapidly under specific treatment. From the effect of other conditions upon them, especially varicose veins, they may assume the character of ordinary varicose ulcers. Prognosis. — The prognosis, aside from the possibilities given, may become serious if an epithelial carcinoma develops in the ulcer, a not infrequent occurrence; it should be remembered that the walls of a benign ulcer may arouse suspicion of malignancy and present difficulties even in microscopical diagnosis. Complications, lymphangitis, erysipe- las, etc., are rather frequent. Treatment. — The extensive, almost endless literature upon the treat- ment of chronic ulcer of the leg and the constant recommendation of new remedies show very clearly the thanklessness of treatment and the poor prospect of permanent cure. Too often it is impossible to maintain the conditions essential to recovery, absolute cleanliness and improved circulation. Whenever it is possible therefore the author keeps the patient in bed with the limb slightly elevated, not only till cicatrization is complete, but also until it has become fairly solid. This often means overcoming the objections of the patient, who is only too much inclined to stand or sit up for a few hours as soon as the condition improves and the pain ceases, or who is unable for social reasons to give the limb the necessary rest and protection. Without denying that the ambulant treatment may be successful under circumstances, nevertheless the conditions for rapid recovery given by the recumbent position are incomparably more favorable. The limb is washed thoroughly with soap and hot water, shaved, and sterilized the same as for operation. The ulcer is dried off with sterile gauze, a wet dressing of 2 per cent, aluminum acetate is applied to the entire leg, and covered with rubber tissue and a retention bandage. This dressing should be renewed two or three times daily at first, later once a day, the skin about the ulcer each time being cleaned and the fat removed with ether. Outside of hospital practice it is simpler to wash the leg two or three times daily for ten to fifteen minutes with soap and warm water, to dry it, and apply a wet dressing of half strength lead subacetate which is renewed three or four times daily. By this method, TNFLAMMA TOBY PROCESSES AND ULCERS OF soft PARTS. 687 which is simple, cheap, and therefore suitable for practice among the poor, the secretion diminishes rapidly and the ulcers become covered with clean granulations, presupposing always that the limb is kept elevated. After the nicer has become clean an ointment promotes the growth of skin. Dusting powders of iodoform, dermatol, orthoform, bismuth, naph- thalin, antinosin, etc., have been used considerably to allay the itching. The author has never found any particular advantage in this method; the ulcers usually become clean more rapidly under moist, warm, antiseptic compresses. The powders may be used to prevent putre- faction, also if moist warmth is not well borne, or for ambulant treat- ment. Naphthalin is good for sluggish ulcers, as it is very stimulating; but as it causes burning pain, increased secretion, and bleeding, it should be discontinued as soon as the ulcer is clean. Orthoform is occasionally useful in diminishing the pain of the*so-ealled erethistic ulcers. Dusting with calomel and moistening with salt solution are very effectual, and have been recommended again recently. The silver nitrate stick, 8 per cent, zinc chloride solution, tincture of iodine and balsam of Peru are sometimes beneficial. The essential of ambulant treatment is a good bandage to prevent congestion. After careful cleansing of the leg and ulcer the latter may be covered with iodoform gauze, an ointment of 2 per cent, silver nitrate, 20 per cent, borovaseline, or ointment of the red oxide of mercury, etc.; over this a thin pad of cotton and the leg then bandaged tightly from the toes to the knee with a 3^ to 4-inch flannel roll bandage; the dress- ing is renewed morning and evening. The skill and care required to apply the bandage smoothly and firmly is unfortunately often absent among the laboring classes, the ones chiefly affected. Binding the leg with a thin rubber roll bandage applied directly over the skin and -the ulcer, as suggested by Martin in America, is even better. The roll is put on smoothly but not tightly; in walking the leg swells, so that a uniform pressure is established; as the rubber prevents evaporation, it acts like a wet compress, stimulating the granulation but often also producing eczema around the ulcer. The bandage has to be washed carefully with soap and cold water at night and kept clean. Guerin's cotton dressing, recommended in Germany by v. Volkmann, is little used. The same applies to Baynton's method of strapping with thin adhesive-plaster strips. Unna's zinc oxide gelatin dressing is very good and has been well tested; Heidenhain recommends the following: warm foot-bath for fifteen to thirty minutes, during which the limb is rubbed with soft soap and lint or cotton. Dry. Sterilization with 1 : 1000 bichloride; the ulcer itself is merely patted gently with the solution. The skin and all spots of eczema are smeared thickly with Lassar's paste, the ulcer dusted with iodoform and then smeared over with red precipitate oint- ment and covered with sterile gauze if the discharge is profuse. The limb is then painted from the toes to the knee and behind to above the knee, with Unna's zinc gelatin (zinc oxide, gelatin, aa 20 parts; glycerin, 688 DISEASES OF THE LEG. water, aa SO parts) warmed, and covered with a starched bandage to the knee, then repainted with gelatin, etc., until four layers of gauze have been applied; the whole is then bandaged with a muslin roll. The dressing becomes hard and dry in twenty-four hours. If there is much discharge, the dressing should be renewed every three days, later every two to four weeks, in general, as soon as the discharge soaks through; at each change careful cleansing and sterilization. Although these dressings allow the patients to go about their work during the entire treatment, nevertheless the author, in view of his experience, is compelled to enforce continuous elevation of the limb till cicatrization is complete, if possible, and only uses the above methods later, after the ulcer has skinned over. Nussbaum recommends excision of the ulcer down to the fascia for old, sluggish indurated ulcers. Occasionally it is beneficial to excise the edges, with or "without scraping the base. Recently skin-grafting has been preferred, and has effected rapid recovery even in the case of large ulcers. Thiersch grafts require an aseptic surface, and should therefore not be applied until the granulations are clean. The attempt to clean them by scraping and sterilizing almost always fails; on the other hand, by waiting till the ulcer is clean, it may be scraped without sterilizing. Gauze is then applied till the bleeding stops, after which the grafts are spread over the entire surface. Transplantation upon a scraped and freshened surface always takes better than upon granulation-tissue. As the grafted skin is always delicate and easily injured, the leg should be wrapped in cotton and elevated for two or three weeks, and later when the patient is up, protected by a dressing, preferably L nna's. Krause recommends grafting with pieces of whole-skin without the subcutaneous fat; Hirschberg advises leaving the latter. If they take — which happens less frequently than with Thiersch grafts — they become slightly discolored but live, and give in fact better protection than the latter. In choosing between the two methods, the possibility of the failure of Krause's or Hirschberg's method should be remembered; and, further, that the spot from which the graft was taken, unless closed by suture, heals more slowly than that shaved for the Thiersch graft. The Italian method goes a step farther than either of the two in forming a pedunculated flap from the other extremity, and is in fact more certain and prevents recurrence better than the other methods. As the skin of the other limb is rarely healthy in the case of patients with chronic ulcers, the method is more adapted to the covering in of traumatic defects of the skin of the ankle or heel. Ligation of the saphenous vein, which is employed successfully at the present time to improve the circulation in cases of varicose ulcers, will be described later. Bardescu and Chipault, in order to hasten and facilitate the healing of varicose ulcers, recommend stretching the nerves supplying the area involved, namely, either the internal or external saphenous, the peroneal, or the musculocutaneous, and report good results. The author cannot give any personal experience in this respect. Mariani speaks in high terms ANEURISMS IN Tin: LEG. of the radical cure obtained by circular incision of the skin and division of all subcutaneous vessels down to the fascia at a point above the ulcer. The after-treatment should aim to prevent recurrence by protecting the cicatrix with an appropriate dressing, to mobilize the cicatrix upon the underlying tissues, and, above all, to overcome any stiffness of the ankle by massage and careful passive and active motion. With a stiff ankle, especially in the pes equinus position, the danger of recurrence is very great. In the very severe cases of old large ulcers extending around the leg and bordered with indurated diseased skin, even though this skin is not ulcerated, it is usually best to amputate the leg, especially if there are elephantiatic thickening of the foot and leg and stiffness of the ankle. Such patients are much better off with a wooden than a diseased leg; they are thus freed from the chronic suppuration and its evil consequences, and are better able to work and support themselves. ANEURISMS IN THE LEG. Aneurism of the arteries of the leg is much less frequent than aneurism of the popliteal artery. In a recent article Vezes could only collect 91 cases from the literature — among these, 5 arteriovenous aneurisms, in which the anterior and posterior tibial arteries were divided about equally; the peroneal was seldom affected alone, but the lower part of the popliteal (truncus tibioperoneus) somewhat more often. The majority of aneurisms were traumatic, following puncture or shot- wounds, and rather frequently fractures of the tibia. In the latter case the tumor in some instances made its appearance immediately after the injury, presumably as the result of impalement or laceration of the wall of the vessel by a sharp fragment; in others it appeared later after gradual erosion of the vessel; exceptionally after removal of the splint. A- a rule traumatic aneurisms enlarge rapidly, the diffuse infiltration of blood into tissues about the sac soon causing severe circulatory disturbances, occasionally gangrene of the foot. Symptoms. — The symptoms are indefinite as long as the tumor is concealed beneath the thick muscles, namely, vague, spasmodic radi- ating pains, paresthesias, pareses, dilatation of the veins of the foot, oedema of the ankle. The diagnosis becomes positive as soon as the increasing tumor gives pulsation and a bruit, and disappears on com- pressing the femoral artery. Large blood-clots in the sac may render the pulsation indistinct. The condition is mistaken chiefly for an abscess or for sarcoma of the bone. Confusion is usually avoidable if these possibilities are remembered. Treatment. — In the case of recent traumatic aneurisms the injured vessel should be explored under application of the Esmarch, the clots removed, and the vessel ligated above and below as soon as possible to prevent severe circulatory disturbance and gangrene. For spon- taneous or older traumatic aneurisms the methods described under aneurism of the popliteal artery may be tried. Constriction of the Vol. Ill— 44 690 DISEASES OF THE LEG. limb by means of an elastic bandage leaving the aneurism free, com- pression of the femoral artery, and ligation above the aneurism, have all given some successful results. In contrast to these successes stand a large number of failures: non-recovery, recurrence, gangrene, death. In view of modern asepsis the author is more inclined to advise radical operation at the outset, either extirpation of the sac or the operation of Antyllus. Although the number of cases of successful extirpation is still too small to be of value statistically, the few favorable results known are encouraging. (See Popliteal Aneurism.) VARICOSE VEINS OF THE LEG. Diseases of the veins of the leg, especially dilatation, are more frequent than diseases of the arteries, the so-called varices being typical of dilata- tion of the veins in general. In spite of the great frequency of varicosities, their etiology is still rather obscure. Mechanical factors preventing the return of venous blood certainly play an important part; regarded as such are certain valvular insufficiencies of the heart, abdominal tumors, especially pregnancy, the wearing of tight garters, tumors at a higher level — in view of the height of the blood-column thus pressing upon the venous valves, and hard work combined with long periods of standing. But these factors alone are not a sufficient explanation; there is no doubt that pregnancy greatly favors the production of varicosities, but that the gravid uterus is not always the essential cause in preventing the return of venous blood is proved by many cases in which the vari- cosities developed to a considerable size in the first months of pregnancy when there could be no question of pressure of the uterus upon the abdominal veins or of any considerable increased intra-abdominal pressure. On the contrary, large abdominal tumors attended by marked intra-abdominal tension are not infrequently unaccompanied by varicose veins. These mechanical factors therefore can be only accorded a co-operative significance; the actual causes leading to atrophy of the walls or of the valves of the veins and to dilatation are unknown. It is certainly not the atrophy of old age, as the disease usually develops between the twentieth and fortieth year, often soon after puberty, and only in few cases after middle life. In the etiology a certain significance is attached to inherited and racial peculiarities. The disease may affect the superficial or deep veins, or both, although it affects preferably the large saphenous vein. (Plate XVIII.) It is rarely spread uniformly throughout the main trunk and its finer branches, but usually more pronounced in certain sections. Sometimes it is chiefly the main trunk and the larger branches which are dilated to the size of the little finger, forming tortuous bluish cords beneath, or projecting into, the skin, particularly in the calf; sometimes one finds a dilatation of the finer and finest branches over a more or less extensive area, especially at the ankle or on the dorsum of the foot, without any great involvement of the larger branches. The dilatation may be fusiform or sacculated. > X h < (X VARICOSE VEINS OF THE LEG. 091 (Fig. 432.) The sluggish circulation or temporary stasis in these dilatations conduces to coagulation; the clot may organize and the nod- ules become obliterated. Calcium salts may be deposited to form the so-called phleboliths, often felt in large numbers under the skin. Not infrequently the irritation causes extensive coagulation, starting from a single nodule and extending through the diseased trunk; large areas are thus thrombosed; eventually the entire saphenous vein or even the femoral. The danger of embolism from loosening of a thrombus is self-evident. In the dilated section the wall is usually more or less Fig. 432. Varicose veins of lea: with large varix in the popliteal space, (v. Bruns.) thickened, but often very thin in places, particularly in the sacculated or nodular varices; rupture is therefore frequent. In the advanced stage the valves become more or less insufficient, by reason of which the insufficiency and the dilatation act reciprocally in producing further dilatation of the vein beyond. The significance of this action is shown by Trendelenburg's test of elevating the limb for a short time, stroking the blood centripetally, and compressing the saphenous trunk; with the vein still compressed the patient then stands, and the varices below fill gradually and only partially with blood from the periphery; on removing the compression the blood rushes down sud- 692 DISEASES OF THE LEG. denly into the veins and distends them instantly ad maximum with all the force imparted to it by the blood-column extending to the heart. Trophic disturbances gradually develop from the effect of the retarded and obstructed venous circulation. The skin of the foot and leg, livid or bluish-red, becomes hard, easily vulnerable, and liable to inflamma- tion, especially eczema; all lesions, even slight abrasions, heal over with difficulty and often become ulcerated. The ankle, and later the entire foot, swells after standing for any length of time, as the result of which a growth of new connective tissue under the skin produces gradual but permanent thickening. The adipose tissue over the varices disappears largely, the nodulated veins become adherent to the skin, which in turn becomes thinner and finally ruptures on the slightest provocation. The hemorrhage from such ruptured varices is easily checked by pressure and elevation, but may otherwise be fatal. The ruptured vein favors the formation of more ulcers. The muscles become relaxed and atrophic, so that the patient is easily fatigued, unable to walk long distances, or even do work requiring protracted standing; secondarily the relaxation may cause flat-foot. The latter and hyperidrosis are very frequent accompaniments of primary varices. Beside the muscular weakness and feeling of tension in the leg, the patients often complain of pains either indefinite or of a shooting character and radiating throughout the leg and foot; occasionally there is typical sciatic neuralgia. Views differ as to whether this is due solely to the pressure of the smaller dilated veins upon the nerves or to an actual secondary neuritis. The discomfort varies greatly and does not always correspond to the amount of visible dilatation. One sees persons in whom the trunks and main branches of the subcutaneous veins have been dilated and tortuous for years without producing any particular subjective disturbance; then again others with very considerable discomfort, but in whom the dilatation is much less pronounced; in general, extensive involvement of large areas of the finer veins apparently produces more discomfort than dilatation confined chiefly to the larger branches. Rupture of the superficial veins has already been mentioned. Rupture of the deeper varices may occur spontaneously or after exertion or trauma. In the author's experience, extending through many years, rupture of the small veins in and beneath the skin is always followed by a macular brownish pigmentation of the skin, especially of the ankle. Rupture of the larger deep veins causes a marked intermus- cular and intramuscular infiltration manifested by a rapidly develop- ing, often extensive and painful hard swelling, especially in the calf; in twenty-four to forty-eight hours ecchymosis becomes distinct and denotes the character of the swelling. The pressure may produce severe circulatory disturbances. A similar acute and painful swelling is caused by inflammation of the deep varices, but the absence of ecchymosis, the rapid appearance of inflammatory redness, the fever, although not always present or high, and the more cord-like and less diffuse character of the deep swelling after the acute symptoms have subsided, make it possible to distinguish the two conditions. Inflammation of the veins is usually VMIICOSE VEINS OF THE LEG. G93 accompanied by thrombosis, and it is not always possible to determine which is primary. Although the inflammation finally disappears in the majority of cases, it may advance to suppuration of the thrombus, or to periphlebitis and phlegmon. The above are the essential points in the symptomatology and diag- nosis of varicose veins of the leg. Varices of the subcutaneous veins are easily recognized. Those affecting the deep veins alone may he mistaken; but as a rule the oedema of the ankle without recognizable internal cause, the dilatation of the finer veins of the skin on the dorsum of the foot and about the ankle, both increased by being on the feet for a long time and improved by elevating the limb, make the diagnosis possible even after comparatively brief observation. Treatment. — It is rarely possible to carry out a causal therapy against varicose veins. It is self-understood that all factors which can be brought to light should be weighed carefully and all hindrances to the return of venous blood removed as far as possible. Any abdominal tumor can be removed, the wearing of tight garters forbidden, and the bad effects of protracted standing pointed out, but on purely social grounds the patient is unable as a rule to meet the latter requirements. A younger person is rarely able to change his occupation for one allowing lighter work and shorter hours on his feet. So the surgeon is generally limited to palliative treatment. The most effectual remedy is naturally to elevate the limb, but this can only be carried out temporarily to over- come complications or relieve especially severe discomfort. As long as the patient is about, the surgeon is limited to preventing the venous congestion by applying uniform compression by means of a flannel or other bandage; or, better still, a well-fitting elastic stocking. As the latter only retains its elasticity for a short time, has to be renewed, and is expensive, it is often beyond the means of the laboring classes, to whom it is most indispensable. Massage, cold baths, followed by active rubbing of the skin, and appropriate exercises to strengthen the muscles, are beneficial; cycling has proved of service in a few instances; on the other hand, riding increases the trouble. This is explained by the fact that in cycling all the muscles of the limb are constantly in motion and thus aid the return of blood, whereas in riding the thigh is pressed firmly against the saddle. Landerer's pad, fitted with a water cushion and having attached to it an elastic metal band with a parabolic curve is useful for compressing the saphenous vein above the varices; if the valves are insufficient it can be applied above or below the knee; it acts the same as ligation in closing the vein, hence, like the latter, it is of value only when the Trendelenburg test is positive. Bruck devised rubber air cushions of various sizes and shapes to be worn over the varices to diminish the pain. Kramer proposed longitudinal incision of the thrombosed veins throughout their entire extent and removal of the clots to relieve the discomfort. A radical procedure is the natural outcome of the inefficacy of pallia- tive measures to relieve the often severe discomfort of this common and 694 DISEASES OF THE LEG. troublesome affection. The various methods aiming to secure recovery by causing thrombosis or obliteration of the veins by the formation of adhesions, namely, compression, cauterization, electropuncture, injec- tion of alcohol or of liquor ferri chloridi, etc., in or about the veins, are only of historic interest, as they were all found ineffectual or dan- gerous. The subcutaneous ligation method of Velpeau and Delpech, later recommended by Schede, has been abandoned for the present method of open ligation, resection, or excision. These latter methods are not new, however, as Celsus ligated for varicose veins. Their permanent place in surgery was first assured by Trendelenburg's demon- stration of the effect of ligating the saphenous vein, by which he showed after ten years' experience in which of the cases success could be expected, namely, in those in which the valves are insufficient. Ligation of the Saphenous Vein.— The saphenous vein is exposed by a longitudinal, or, better, a transverse incision at the junction of the upper and middle third of the thigh; the vein is double ligated and divided, or, better, a piece \ to 1 inch long is cut out between the ligatures. The application of the Esmarch is immaterial. The site of incision, however, is important, as the mistake is frequently made of hunting for the vein too close beneath the surface if it cannot be seen — e.g., in stout subjects; local cocaine anaesthesia is sufficient. Many surgeons advise ligating the saphenous just below its junction with the femoral in order to meet the possibility of unusually high branching, otherwise each branch has to be ligated separately. Since Trendelenburg's publication in 1S91 the favorable results of the operation have been confirmed by many authors, and the intervening time has been sufficiently long to enable one to judge of the protection afforded against recurrence. In appropriate cases the relief follows quickly; the wound heals by primary intention in about ten days, any existing ulcers heal over rapidly and permanently if not too large, and provided that they are kept clean and protected; the number of recur- rences is small. It cannot be denied, however, that the operation is not without its dangers; in spite of complete asepsis, thrombosis of the proxi- mal stump and embolism have occurred, a warning against operating without a strict indication. If the external pudic or the superficial epigastric veins open into the saphenous, Ledderhose recommends that they be ligated. To overcome the troublesome oedema of the leg, in addition to ligating the saphenous vein he makes several longitudinal incisions from the ankle to the knee, and with the limb in the vertical position also others at the sides and behind, carrying them through the skin and subcutaneous tissue down to the fascia of the muscle ; afterward he closes them with continuous sutures and applies a dressing with pressure. Excision of varicose veins is a larger operation. Although performed in the preantiseptic period, its value was first established after the introduction of asepsis; recently it has been especially recommended by Madelung. On account of the gradual dilatation of the collaterals, the operation does not always prevent recurrence, but may be successful ELEPHANTIASIS OE THE LEG, 695 where the insufficiency of the valves is not pronounced; as numerous communications are thereby cut off the danger of recurrence is slight. Particularly in tlie eases in which entire networks of veins, like an angioma, distend the skin or are thrombosed, the author usually excises these masses in addition to ligating the saphenous. To avoid making one long incision in excising the saphenous vein, Casati recom- mends multiple incisions 1 V inches long, the sections of vein between being removed subcutaneously; he does not ligate the lateral branches. ELEPHANTIASIS OF THE LEG. The affection known as elephantiasis Arabum may be regarded as the result of severe circulatory disturbances, of repeated attacks of arterial hyperemia, of chronic obstruction of the venous circulation, and espe- cially as a disease of the lymphatics. Although met with everywhere, and endemic in the tropics, it is seen only sporadically in and about Germany [and America]. In spite of its great scientific interest it is of slight clinical significance on account of its infre(|uency. It is essentially a chronic inflammation, leading to thickening of the skin and subcutis through growth of connective tissue, and often causes enormous increase in the size of the parts involved, chiefly the leg. Elephantiasis begins as a rule between the fifteenth and twentieth years, rarely earlier, and seldom after the thirtieth year. The onset is like that of an acute lymphangitis, and in the endemic form often attacks a previously healthy limb; but in the sporadic form, as it occurs chiefly in Germany, it more frequently follows long-standing irritation, espe- cially chronic ulcers. The initial chill, fever, and general malaise are accompanied by the appearance of a hot, tender swelling in the leg, over which the skin is reddened and streaked in lines corresponding to the lymphatics and usually extending up to the knee. The attack lasts one to five days; the inflammatory changes may subside completely; a slight swelling often persists, however, after the first attack. The attacks are repeated at varying intervals of weeks or months with the same symp- toms but with less intensity. The condition has been looked upon as being an erysipelas, but this is wrong, although infectious processes unquestionably play a certain part in the inflammatory exacerbations. As the attacks increase, the continuous swelling which was at first soft becomes more solid, the skin becomes thickened and more firmly adherent to its substratum, and can be pitted in only a few places. In five to ten years the leg, especially the lower half, becomes greatly enlarged, the thickened (verrucous) skin is thrown into heavy folds which hang down over the normal or involved foot to the ground, the folds containing epithelial detritus, sebum, and dirt. (Fig. 433.) The epidermis becomes greatly thickened in the form of flat plates or horny callosities, or it has more the appearance of a papilloma if the papilla? are involved; the wart- like projections, the size of a millet-seed or lentil and separated by deep furrows, give the skin the appearance of a coat of mail. The decompo- 696 DISEASES OF THE LEG. sition of the sweat and oils from the skin leads to the production of extensive eczema and ulcers with a penetrating foul odor. The muscles atrophy and the bone becomes somewhat involved in the thickening. In spite of the muscular weakness and the impaired mobility of the ankle- joint due to the shapeless swelling of the foot and leg, the patient may still be able to walk for some time and to some distance; occasionally the functional disturbance is marked at an early period. The etiology and essential pathogenesis is still obscure in spite of numerous investigations. From Teichmann's studies it is known at least that the disease is due to changes both in the bloodvessels and in Fig. 433. Elephantiasis of the 1 the lymphatics. The superficial lymph-capillaries and lymph-spaces are much dilated; the deeper lymphatics are replaced by lymph-cells or become thrombosed or narrowed even to obliteration by a growth of the endothelium. The glands are occasionally enlarged and solid, but otherwise without intrinsic changes. Prognosis. — The prognosis of the disease is very unfavorable. Although the general condition of the patient often remains unchanged for many years, the local affection usually advances slowly but steadily. Treatment. — In recent cases the limb is elevated, compression band- ages applied, the limb massaged, and by strict cleanliness all inflamma- tory irritation prevented. Compression of the large arteries with the ACUTE OSTEOMYELITIS OF THE BONES OF THE LEG, 097 finger or tourniquet, repeated frequently for several hours, lias been warmly recommended. Especially troublesome hypertrophied ma nf skin have been excised. Carnochan and others recommend ligation of the femoral artery in severe eases; the swelling diminishes to some extent l>ut the result is very uncertain, almost always only temporary. The operation has occasionally been followed by gangrene of the leg, and has therefore been almost entirely abandoned. ACUTE OSTEOMYELITIS OF THE BONES OF THE LEG. Acute osteomyelitis attacks no other bone so frequently as the tibia, either alone or simultaneously with other long bones; according to V. Brans, the tibia was affected in 42 per cent, of all cases, the fibula in only 3 per cent. The favorite site of the disease is the spongiosa of the shaft between the epiphyseal line and the medulla, although it very often spreads to the medulla at an early period. The upper and lower ends of the shaft are not infrequently involved simultaneously or in close sequence while the middle of the shaft is left free, or the inflamma- tion may extend rapidly through the entire shaft. The epiphyses are frequently involved secondarily, rarely primarily; in the head of the tibia particularly the suppuration is liable to advance rapidly through the meshes of the spongiosa to the articular cartilage. Symptoms. — The clinical picture and the form of the disease vary as much as the site and distribution. In the tibia one sees both the sub- acute and the chronic forms of periostitis albuminosa (Oilier, Schlange, Garre); the purulent ichorous form, rapidly fatal in a few days with the symptoms of a severe general infection; also sclerosing ostitis with merely marked thickening of the bone; and further, severe suppurating osteomyelitis and periostitis with perforation and partial or complete necrosis; all these forms are apparently independent of the nature of the bacteria. Although the type of osteomyelitis following typhoid and produced by the typhoid bacillus is as a rale merely a circum- scribed focus with thickening due to growth of the periosteum or in addition containing a small abscess with or without the formation of a small sequestrum, and although Staphylococcus pyogenes albus is more frequently found in the mild cases and Staphylococcus pyogenes aureus or Streptococcus pyogenes are rarely absent in the severe cases, nevertheless Garre has found Staphylococcus pyogenes aureus in pure culture in relatively simple periostitis albuminosa, and vice versa Staphylococcus pyogenes albus has been found alone or with the typhoid bacillus in the very severe cases. The onset is usually accompanied by severe chills, high fever, and severe constitutional disturbance. If the sensorium is not immediately dulled, as sometimes happens in very severe cases, the intense pain is referred to the seat of the disease. Even if the patient is in a condition of stupor, careful search of the entire body for a point of tenderness, taken in connection with the generally complete loss of function and relaxation of the affected limb, will reveal the seat and G98 DISEASES OF THE LEG. nature of the disease. The important objective symptoms, first of all, the swelling corresponding to the spot of greatest tenderness, appear early on account of the superficial position of the tibia; as the swelling is due to subperiosteal exudation, it is firm at the outset and feels like a protrusion of the bone itself. According to its extent, it is limited to part of the anterior surface of the tibia or involves the entire length of the shaft. At the outset the overlying soft parts are sharply defined, but soon become infiltrated, swollen, oedematous, the skin red and often containing a bluish spot. If the disease is limited, the oedema also extends only slightly beyond it; if diffuse or in the upper and lower part of the shaft, the oedema may extend over the leg and foot and beyond the knee. The subcutaneous veins are often greatly dilated and visible through the tense, glossy skin. At this stage the affection could only be confused with severe phlegmon, an error of slight significance, as the necessary incision would reveal the condition in either case. The sub- periosteal abscess, opened by incising, in the first few days usually con- tains, not pure yellow, but also bloody, discolored pus. It spreads out over a varying extent of the smooth surface of the shaft, occasionally from one epiphyseal line to the other. After incision or perforation the fever and pain generally subside entirely if the disease is in the form of a limited suppurative periostitis; if the bone is involved at the same time, the fever and pain disappear only after the medulla has been opened or the pus has perforated out- ward. Perforation may occur at any point, but is most common in front and to the outer side; gravitation abscesses of any size in the region of the calf are not a frequent occurrence. If the abscess is incised early, the periosteum may grow back upon the bone; and if only a small area is affected, it may heal without necro- sis or the formation of a sinus, only a slight thickening of the periosteum being left. In the majority of cases, however, especially with diffuse suppuration about and in the bone, necrosis cannot be prevented even by early incision; the periosteum becomes readherent in part, but in one or more places a discharging fistula is left, through which the probe strikes a sequestrum. The sequestrum may be small and superficial, or be large at the end of the shaft, in which case the continuity of the shaft is maintained only by narrow strips of the old bone together with the "coffin" of proliferated periosteum formed; in other instances the entire shaft is destroyed. This is the usual course, so that the diagnosis can be made early, even in the first few days, without difficulty ; variations, however, are not infrequent. Occasionally it is more subacute, with slight, or at times almost no fever. A moderate and limited swelling develops with some pain and without severe constitutional disturbance; fluctua- tion becomes distinct in the course of a few weeks and a small cortical sequestrum is thrown off; if situated near the epiphysis, the condition suggests a tuberculous ostitis, but its character is determined eventually by the nature of the pus, the formation of a sequestrum, and the rela- tively rapid recovery after the latter has been thrown off. ACUTE OSTEOMYELITIS OF THE HOSES OF THE LEO. 699 The rare periostitis albuminosa has the acute onset, the fever, and the same sequestrum formation as the ordinary form, but progresses without suppuration, gives a more or less serous exudation, and later has a more subacute course, existing for months before perforating. The equally rare non-purulent sclerosing form of osteomyelitis ((Jarre), according to Haaga, has been seen in only 20 of 559 cases of osteomyelitis; it merely produces thickening of the hone. \n the majority of cases of this kind the disease begins with an acute onset in the typical manner, and progresses with high fever, swelling of the extremity, tenderness Fig. 434. Loss of growth following osteomyelitis of the tibia, necessitating the removal of part of the shaft. (Whitman.) and swelling of the bone, and even marked infiltration of the soft parts; but the stormy symptoms disappear rapidly, the swelling of the soft parts subsides slowly, and recovery follows gradually without perfora- tion. If seen at a more advanced stage, it may suggest chronic inflam- mation, especially syphilitic ostitis, but the acute onset with high fever, the absence of other signs of syphilis or tuberculosis, and the relatively frequent occurrence of typical suppurative osteomyelitis previously or simultaneously in other bones, distinguish the affection from the dis- eases in question. Miiller recently described as a rare result of acute osteomyelitis a growth of a series of hard tumors each containing a small sequestrum. 700 DISEASES OF THE LEG. A frequent complication of acute osteomyelitis of the tibia is an inflam- mation of the knee- or ankle-joint, or of both, as a rule appearing in the eighth to tenth day of the disease. The effusion may be serous, or in severe cases thickly purulent with red cells and fibrin, but is usually seropurulent. The knee is generally flexed slightly and the foot held extended. The joint-affection is denoted further by pain, swelling, and generally by distinct fluctuation; redness of the skin, although commonly present, is usually slight. The character of the effusion can generally be determined only by aspiration. The purulent form is commonly followed by some permanent disturbance even with proper treatment; the serous form is followed by full recovery, but the sero- purulent form only exceptionally. Separation of the epiphysis is not a rare occurrence in the course of acute osteomyelitis of the tibia or fibula; recovery may be by firm, bony union, but the latter may be absent if the periosteum is destroyed by suppuration. The treatment should aim to hold the fragments in good position. A rare form of bone abscess found several times in the head of the tibia, and first described by Brodie, should also be mentioned. It is an extremely chronic disease, extending over many years, which can only be referred, however, to acute infectious osteomyelitis. Pathologically it consists of an abscess of the size of a hazelnut or walnut, surrounded by a thick wall of sclerosed bone lined with a thin layer of granulation- tissue somewhat similar to mucous membrane. The clinical picture suggests the above-mentioned sclerosing form, namely, the acute onset, swelling, and permanent thickening of the bone; but the abscess does not heal. Often considerable pain persists, disappearing possibly for periods of days or weeks, but always recurring, and occasionally becom- ing unendurable at night. The diagnosis can generally be made only with a certain probability from the acute onset, the insidious course, and the failure of all, especially specific, treatment. It can be made posi- tively only by exploratory trephining, or preferably chiselling of < the bone. The disturbances in growth clue to osteomyelitis are of particular interest. According; as the inflammation is situated near the line of the epiphyseal cartilage and irritates it, or extends into it and destroys it, the bone may be lengthened, even § to 1} inches, or shortened, the more frequent result. Lengthening of the tibia tends to produce a flat-foot position (eversion), shortening a club-foot position (inversion) of the foot. The normal fibula thus becomes somewhat curved and partially dislocated at the tibiofibular joints; if the growth of the tibia is arrested, the head of the fibula is gradually displaced upward and projects at the outer side of the knee-joint. Treatment. — The insidious, occasionally severe course of acute sup- purative osteomyelitis calls for energetic treatment. The old teaching to await the formation of the abscess and simply open it, is being more and more abandoned for that of early free incision and evacuation. Too much, however, cannot be expected of early radical operation, as ACUTE OSTEOMYELITIS OF THE BONES OF THE LEG. 7Q1 severe general infection only too often complicates the condition so early thai operation cannol prevenl fatal septicaemia. Nevertheless it is sometimes possible to check the process or prevent or limit necrosis. The superficial position of the tibia facilitates early operation. Under application of the Esmarch a longitudinal incision is made over the front of the tibia, the periosteum is peeled off with an elevator and with a curved chisel the entire area of infiltration is exposed and all diseased bone scraped and chiselled out. Foci in the epiphyses should be scraped out carefully to prevenl secondary infection of the joint; the cartilage should be saved as much as possible. The wound is packed with iodoform gauze, covered with a large dressing, and the limb ele- vated in a Volkmann splint. The operation should be thorough but as rapid and limited as possible, in view of the weakness of the patient due to severe constitutional disturbance. If first seen after the abscess has formed and after the severe constitu- tional symptoms have subsided, or if the process is more subacute, it is better merely to open the abscess freely and await the separation of the sequestrum and the formation of the "coffin." Involvement of the knee- or ankle-joint requires aspiration and irrigation with 3 per cent, carbolic solution or eventually free incision and drainage. The sclero- sing form does not require operation, but merely rest, elevation, and warm baths, especially hot compresses to aid resorption. If the pain continues or shows frequent exacerbations, the bone should be incised and the spongiosa, usually filled with grayish-red or yellowish granu- lations, scraped out; the same rule applies to abscess of the bone. The formation of the sequestrum in the bones of the leg in the event of spontaneous recovery or after early or late incision does not differ essentially from the usual process elsewhere. The growth of periosteum, the so-called "coffin" (Todtenlade), and the consequent thickening of the bone, is of practical importance, as its limits correspond very closely to the extent of necrosis, so that by inspec- tion and palpation of the surface of the tibia or fibula one may estimate approximately the amount of exposure necessary. If delay is war- ranted by the general condition, the fever, and suppuration, one should wait until the sequestrum is completely separated and the periosteum has formed a sufficiently solid "coffin." On this surgeons are almost all agreed, dishing recommends removal of the sequestrum before this growth is complete; on incising the periosteum at this stage a dis- tinct grating is felt under the knife, while macroscopically there is no evidence of bone formation. As to the best method of sequestrotomy the views are still divided. The older method, which still has many distinguished advocates, such as Konig, merely splits the sinus, widens the opening into the bone, removes the sequestrum as a whole or in pieces, and scrapes out the cavity. It has the advantage of preserving the new shell of bone in its entire extent and therefore of weakening the limb as little as possible, and of avoiding injury of the areas of delicate cicatricial tissue adher- ent to the bone. Its great disadvantage is that it prevents thorough 702 DISEASES OF THE LEG. inspection and removal of all diseased bone, so that infiltrated spots or even small sequestra are easily overlooked and form the basis of fresh and often long-continued suppuration and recurrence. Modern methods aim to expose the entire affected area through an appropriately long incision. Sinuses are split or excised. The bone is chiselled away till the limits of the process are well exposed, and the sequestrum and all granulations are then Fig. 435. removed with the chisel and sharp spoon. The . ji continuity of the bone should never be entirely destroyed if possible; if the sinuses are numerous and scattered, it may be impossible to avoid remov- ing all but a small bridge of bone. Where the suppuration extends high up into the head of the tibia the joint should be carefully avoided. The cavity is packed. To shorten the period of re- covery and to improve the general character of the resulting wound, v. Esmarch cut down the edges of the cavity and in it implanted the soft parts from both sides, holding them in position by sutures and pressure. Neuber nailed the flaps to the walls of the cavity. Schede blood-clots the cavity ; this method has not fulfilled the former expectation held in regard to it, as even with the greatest care complete asepsis is rare. Senn, Kummell, Drees- mann, Sonnenburg, Mayer, Stenson, Heintze, and others have recommended implantation of decal- cified bone, plaster, cement, copper amalgam, in the same way that a tooth is filled, but so far the pro- cedures have met with little success. Liicke and Ollier's osteoplastic methods are better; they con- sist essentially in making a long quadrilateral flap of skin, periosteum, and bone, which is chiselled off, turned back, and after the cavity has been cleaned, implanted in it. Bier's method (Fig. 435), especially adapted to the tibia, differs from Liicke's only in that the flap is sutured back in place instead of being implanted in the cavity, thus giving a better appearance, although the principle of Liicke's method appears to the author to be more nearly correct. [At the International Medical Congress held in Madrid, in April, 1903, Silbermark 1 explained that the failure of the various methods of plugging bone cavities was due to the fact that the materials used thus far had acted as foreign bodies and been cast off with profuse suppura- tion, v. Mosetig, however, had found a substance which did not act as a foreign body and was completely absorbed and replaced by granu- Osteoplastic necrotomy of the tibia. (Bier.) [! Munch, med. Wochenschrift, 1903, No. 20.] TUBERCULOSIS OF THE BOSKS OF THE LEG. 703 lations until the cavity was entirely filled with new hone, it being possible to study the concentric diminution of the cavity with the ./-raw Silber- mark reported 121 cases with 44") cavities which hud been treated suc- cessfully by v. Mosetig. He also mentioned an electrical instrument which he had made to lighten the task of cleaning out the cavity. The method, as reported by v. Mosetig, before the Gesellschaft fur Aer/te, in Vienna, in January of the same year, 1 and which he had used during the previous three years in over 100 cases of caries and necrosis, was as follows: Under application of the Esmarch and with strict anti- sepsis, the periosteum was lifted off and all diseased tissue removed thoroughly with sharp spoon, saw, chisel, etc., until positive that the cavity was aseptic. The result depended upon the latter condition and the sterility of the filling. The filling consists of iodoform, 00.0; sperma- ceti and oleum sesami, aa 40.0; heated slowly to 100° C. in a flask on a water-bath; kept at this temperature for fifteen minutes; then removed and allowed to cool and solidify, while shaking constantly. Before using, it is melted and heated to 50° C. in a thermostat. After the cavity has been cleansed of all diseased tissue, it is washed out thoroughly with a 1 per cent, solution of formalin, dried out with swabs and then with hot air and filled with the melted mixture. The periosteum and skin are then sutured without drainage and a dressing applied. In fourteen days, in the case of knee resection in twenty-one days, the dressing is changed and the skin sutures removed. The course is almost afebrile and there is never iodoform intoxication. The hardened filling is grad- ually replaced by granulations and new bone, as demonstrated by the a;-ray (Holzknecht). The patient can be about. The size of the cavity, according to Silbermark, is no contraindication; in some instances two-thirds of the shaft having been removed and replaced by the filling. The same author 2 emphasizes the importance of absolutely checking all bleeding and drying out the cavity with hot air, and describes the electrical hot-air apparatus used in v. Mosetig's clinic. 3 To check the oozing of blood even more surely, Damianos 4 swabs out the cavity with adrenalin pledgets after thorough cleansing and drying with hot air. He cites 150 cases treated successfully, and attributes the results to extreme care in the technic and in determining the time of operation. According to Damianos, v. Mosetig prefers a flap section to direct incision. In chronic osteomyelitis the cavity can be plugged at once, but in acute cases not until several weeks after the onset.] TUBERCULOSIS OF THE BONES OF THE LEG. Tuberculous foci, "granulation" foci, and sequestra are found rather frequently in the epiphyses of the bones of the leg. They often give rise to secondary tuberculosis of the knee or ankle. The head of the [! Munch, med. Wochenschrift, 1903, No. 2. - Zentralblatt f. Chirurgie, 1903, No. 25. 3 Deutsche Zeitschrift f. Chirurgie, Band lxvi. p. 589. * Zentralblatt f. Chirurgie, 1904, No. 6.] 704 DISEASES OF THE LEG. Fig. 436. tibia is the seat of choice. Moderate, dull pain, continuing for weeks or months, increased by pressure and associated with a flat thickening of the head of the tibia near the spine which develops gradually and points clearly to growth of the periosteum, should always awaken sus- picion of a tuberculous focus in the bone, especially if the patient gives evidence of tuberculosis elsewhere or a history of tuberculous heredity. The diagnosis is positive as soon as a cold abscess forms. This is often the first symptom; at least the changes may be so slight as to have been previously unnoticed by the patient or relatives. The knee-joint may be uninvolved. It is important to recognize the condition at this stage, as by timely evacuation of the focus perforation into the knee can be prevented. The same applies to foci in the lower epiphysis. Tuber- culosis is not infrequently confused with acute or subacute osteomyelitis of the epiphysis, but the acute onset of the latter with high fever, severe pain, and the ab- sence of symptoms of tuberculosis else- where, the character of the pus and the granulations of the sinus, all point to an osteomyelitic process. After all, an error is not serious clinically as the treatment is the same in both cases. The reverse process, namely, secondary involvement of the epiphysis from a pri- mary tuberculosis of the knee or ankle, is also often seen. Tuberculosis of the shaft is much less common and less known, and is divisible into three groups: 1. By trans- mission from a process in the joint or epiphysis. 2. Primary of the spongiosa, with or without an independent process in the epiphysis, in the form of (a) a granu- lation focus, (b) sequestrum, or (c) pro- gressive infiltrating caseation. 3. Primary tuberculous osteomyelitis: (a) circumscribed foci, (b) involving the entire medulla and generally leading to partial sequestration. (Fig. 436.) Anatomically and clinically the process is quite analogous to that in the epiphysis or in the spongiosa; but on ac- count of its rarity one does not always think immediately of tuberculosis. Although in comparison to acute osteomyelitis the course is usually more insidious and chronic, the onset is occasionally rather acute and the course more subacute. In this case the diagnosis may be first made at the operation by the thin, cheesy, or crumbling pus, the grayish-red pyogenic membrane studded with tuber- cles lining the abscess cavity, the scattered, cheesy granulations, and the grayish-yellow porous sequestrum partly honeycombed with granu- Tuberculous osteomyelitis of the of the tibia. SYPHILIS OF THE BOXES OF THE LEG. 705 lations. The author has seen this rare affection chiefly in children, especially those with multiple foci of tuberculosis. Treatment. — Unless the poor general condition and an extension of the local process demand amputation of the limb, the treatment is con- fined to tree exposure and thorough removal of the focus. SYPHILIS OF THE BONES OF THE LEG. Acquired syphilis appears in various forms in its seat of choice in the bones, the tibia; it is less frequent, although not rare, in the fibula. Syphilitic periostitis is the form most generally known, leading to the production at one or more spots of flat, firm, later more rounded gummata, soft in the middle, and finely pseudofluctuating; the bone becomes irregularly absorbed and exostoses grow out around it; the tumor becomes adherent to the skin, perforates, and gives a characteristic sharply defined crater-like specific ulcer with a greasy membrane; after the process heals, the surface of the bone remains very irregular, the cicatricial scars of the skin being adherent to the deep depressions in the bone. Particularly the spine of the tibia loses its sharp outline; long after recovery one can make a probable diagnosis of syphilis from the changed form of the bone. Gummatous osteomyelitis of the tibia is not less frequent, possibly more so; some syphilographers, like Gangolphe, assume at least that it is always associated with syphilitic periostitis. The gumma may develop in the spongiosa or the medulla as a circumscribed tumor or it may spread diffusely. Like all granulation-tissue, it absorbs the bone, but irritates the periosteum to the formation of a thick circumscribed or diffuse periostosis or hyperostosis. Spontaneous fracture may occur if proliferation does not keep pace with absorption of the bone. Syphilis of the bone may give no symptoms for a long while. Usually the patient complains of a long-standing dull, aching pain, with periods of diminution and exacerbation, the latter especially at night (dolores osteocopi). This in connection with a palpable thickening of the bone usually leads to the proper diagnosis as soon as a history of syphilis is obtained. In the absence of such a history the surgeon thinks of subacute osteomyelitis, abscess of the bone, tuberculosis, and especially periosteal or myeloid tumors. But osteomyelitis begins more violently: with abscess of the bone there is usually a history of previous osteomyelitis; malignant neoplasms generally grow more rapidly and are more sharply defined. Nevertheless in individual cases the diagnosis is often difficult. In doubtful cases specific treatment should always be tried first. Gum- mata react rather promptly to large doses of potassium iodide; the pain diminishes but the thickening of the bone persists except in as far as it is due to periosteal gummatous nodules. Congenital syphilis sometimes comes to light in the form of an osteo- chondritis; it is seen rather frequently in the upper epiphysis of the tibia (Wegner), with shortening or lengthening of the bone according as the Vol. ILL— 45 706 DISEASES OF THE LEO. epiphyseal line is destroyed or merely irritated. A second form is the ossifying periostitis; gummata are rare. The inflammation of the skin and bone leads gradually to the formation of a diffuse, less frequently circumscribed, thickening of the bone. The growth of periosteum is at first moderately firm with softer spots, but gradually becomes bony hard. The growth is accompanied by moderate pain varying in intensity. The hyperostosis is not a uniform growth and frequently gives an increased forward convexity to the shaft; in other cases it produces lateral flattening, sabre-sheath form, as in rhachitis. A certain amount of lengthening usually takes place in the bone at the same time and with the same result as produced by lengthening of the tibia due to osteo- myelitis, namely, development of an anomalous position of the foot and knee, flat-foot and genu valgum. The treatment of syphilis of the bones does not differ from the usual specific measures. RHACHITIC CURVATURES OF THE LEG. Fig. 437. Rhachitis produces changes in the bones of the leg as severe as they are frequent. While thickening, occasionally infraction, of the epiphyseal cartilage is seen chiefly in the first year, the deformities due to muscular traction and encumbrance when the child begins to walk are most frequent in the first to the fifth year. After the sixth year the number of cases of cur- vature diminishes considerably from the fact that in a large number of instances recovery takes place as the result of growth. The deflexions of the upper epiphyseal end of the tibia were discussed under genu valgum and genu varum. Farther down in the leg the site, direc- tion, and degree of curvature vary greatly. Only the principal varieties will be discussed. One of the most common is the outward curvature of the entire limb, the well-known "bow-leg." The curvature may be unilateral or bilateral, or one leg bowed out and the other bowed in (" knock-knee"). Often in connection with bow-leg the lower third or fourth of the leg may be inflexed and rotated backward and inward, the angular prom- inence facing forward, the toes turned inward (anterior bow-leg, Fig. 437). If the deformity is severe, the foot is usually held everted in the valgus position, otherwise the child would walk only on the outer edge of the foot, although it not infrequently happens that the foot turns in in Anterior bow-leg. (Reiner.) X X < nuAcmric crnvArriiEs of the lec. 707 walking. Inflexion, convex forward, at the junction of the lower and third fourth of the leg, is quite characteristic and very disfiguring; the lower end of the leg may form a right or even acute angle with the shaft; the curvature is usually combined with lateral flattening, sabre- sheath form; the anteroposterior diameter of the bone is increased at the angle; the feet are held slightly Hexed and are greatly flattened. It is in the very severe eases of rhachitis that one frequently sees curvatures in the middle and lower third convex backward and inward. On account of the weakness of the bones and the painfulness of efforts to walk, rhachitic children often do not learn to walk until the Fig. 438. a (a) Rhachitic bow-legs in a three-year-old child, (b) The same two years later. Height 42 inches. (Veit.) fourth or even fifth year. After the bone has become hard they can walk fairly well, but the gait is always clumsy and waddling on account of the curvature and the position of the foot. The course of the affection depends, aside from the degree of deformity and the time at which the disease itself disappears, essentially upon the growth of the bones. If growth progresses in a normal manner, the curvature may decrease or even disappear without treatment, as Schlange and Veit, and Kamps have demonstrated very clearly, and as the laity have known for a long while. (Figs. 438 and 439.) This is especially true of the cases of genu valgum or varum due to curvature of the upper epiphysis. If growth is retarded, which is always the case if the disease is severe and protracted, the deformity persists accordingly. 708 DISEASES OF THE LEG. Wit found that the improvement due to growth alone ended generally by the sixth year, although slight improvement could be expected tiil the tenth year. Treatment. — In the first two years the treatment is generally of the rhachitis itself and of the condition of the body, prohibiting injudicious walking while the disease is active. Orthopaedic treatment is hardly necessary till the fifth year. If the bones are markedly curved but soft, they can be straightened by hand and held by means of liffht splints. The demands of the parents often compel one, without having any definite provocation, to straighten the limbs by means of orthopaedic apparatus. Such apparatus, however, have to fit accurately and must Fig. 440. ^ M i ^ (a) Rhachitic bow-leg and knock-knee in a three-year-old girl. Height 41 54 inches. (6) Same two years later. Height 44 inches. (Veit.) be watched carefully to prevent decubitus or improper action; further, they are cumbersome, prevent free use of the muscles, and are little adapted for service among poor people, the class among whom the severest forms occur most frequently. Surgical treatment is necessary if the curvature, and especially the functional disturbance, persists after the fifth or sixth year. The disad- vantages of the orthopaedic apparatus mentioned make rapid correction preferable; as the bones are usually thick and solid after the disease has disappeared, manual strength alone is generally ineffectual. In France and Italy improved osteoclasts have been much used recently; in Germany osteotomy is preferred, as it is practically harmless and TUMORS OF THE LEG. 70f motion in the tibiotarsal joint is about 78 degrees, and is composed about equally of flexion and extension measured from the mid-position. (Weber brothers.) It is checked partially by the biarthrodial and poly- arthrodial arrangement of the muscles; for example, with the knee Hexed, the range of flexion of the foot is greater than with the knee extended. Moreover, extension is checked by the anterior, flexion bv the posterior ligaments. In extension the posterior margin of the tibia, in flexion the anterior margin, impinges against the projecting part of the astragalus. The mediotarml joint (talotarsal) is composed of the joints between the astragalus and scaphoid, the astragalus and calcaneum, and calcaneum and cuboid, motion in the two former being always accompanied by motion in the latter. The movements permitted are outward rotation of the tip of the foot — abduction — and inward rotation— adduction. In abduction the outer border of the foot is also raised, and the inner border lowered at the same time; in adduction the inner border is raised and the outer lowered; this rotation about the long axis of the foot is termed pronation (eversion) and supination (inversion), analo- gous to the rotation of the hand, and as abduction and pronation and adduction and supination cannot be carried out independently, one often speaks merely of pronation and supination of the foot. 1 Motion takes place chiefly between the astragalus and scaphoid, but also simul- taneously between the calcaneum and cuboid, hence in the so-called Cho- part's joint-line. The articular surface of the head of the astragalus is not spherical, but more convex laterally than from above downward. The cotyloid surface of the scaphoid moves on it in an axis directed from the tuberosity of the calcaneum forward and upward to the head of the astragalus at an angle of about 45 degrees to the long axis of the foot in the mid-position. As this axis is also directed somewhat inward, the front of the foot is lowered or elevated slightly in adduction or abduction. In adduction the front end of the calcaneum turns inward and downward beneath the head of the astragalus, the outer surface turns downward, the inner upward. This rotation is transmitted to the cuboid and the outer border of the foot is depressed and rotated inward. The range of motion in the mediotarsal joint is estimated variously, the highest being 42 degrees. It is checked directly only in the calcaneo- astragaloid joint in that in forced abduction the anterior process of the calcaneum impinges against the anterior surface of the free outer margin of the astragalus in front of the external malleolus, and in forced adduc- 1 To avoid the confusion caused occasionally by the author's use interchangeably of abduction and pronation (eversion) and adduction and supination (inversion), the terms eversion and inver- sion will be used to signify rotation of the foot about a horizontal axis (long axis of foot), and abduction and adduction rotation about a vertical axis (axis of leg). Physiologically considered, eversion and inversion imply a certain amount of abduction and adduction, but not mechanically — e.g., in pure eversion fractures of the malleoli and pure eversion sprains and dislocations of the ankle. Although the same physiological considerations apply inversely to abduction and adduc- tion, it is practical for the sake of clearness to limit abduction and adduction to rotation about the vertical axis, as far as possible. 720 MALFORMATIONS AND DISEASES OF ANKLE AND FOOT. tion by the impingement of the posterior end of the sustentaculum against the inner margin of the astragalus; in the two other joints motion is limited only by the ligaments, not by the bones. The internal lateral ligament (deltoid ligament), together with the inferior calcaneonavicular ligament covering the head of the astragalus, prevents abnormal abduction of the foot and sinking of the arch (flat- foot). The ligaments in the sinus tarsi are very short but firm, and hold the bones together without preventing motion, as they lie centrally. The synovial cavity of the large joint between the astragalus and calcaneum is separated from the smaller joint between the sustentaculum Fig. 449, External malleolar artery. External malleolus. Tendon of the peroneus brevis. Extensor minimi digiti. Tendon of the, peroneus tertins In terosseous artery (I, II, III, IV). Interosseous m usclei (I, II, III, IV) Transverse ligament (upper band of anterior annular ligament). Anterior tibial artery. Anterior tibial nerve. Tendon of the tibialis anticus. Cruciate ligament (lower band of anterior annular ligament). Internal malleolar artery. Tarsal branch of dorsalis pedis artery. —Dursalis pedis artery. Anterior tibial nerve. Tendon of the extensor longus hallucis. Tendon of the extensor communis diffitorum. — Dorsalis hallucis artery. Metatarsal artery. Tendon of extensor proprius hallucis. Digital brunches of the dorsalis pedis artery. Dorsal surface of foot and ankle. (Joessel.) and neck of the astragalus in front by the ligaments of the sinus tarsi; the smaller joint communicates with the astragaloscaphoid joint, which in turn is separated from the synovial cavity of the calcaneocuboid joint. The topography of the muscles, tendons, nerves, and vessels is pre- sumably well known. We should indicate that all the muscles running to the foot in front of the transverse axis of the tibiotarsal joint, namely, the tibialis anticus, extensor hallucis, and extensor communis digitorum, are flexors (dorsal flexors) of the foot, those behind the axis, the tibialis posticus, flexor digitorum, flexor hallucis, the peronei, and especially the gastrocnemius and soleus, are extensors (plantar flexors). All these mus- cles also produce rotation about the oblique sagittal axis; those attached MALFORMATIONS AND DISEASES OF ANKLE AND FOOT. 721 on the inner side of the axis addud and invert: tibialis posticus, flexor hallucis, flexor digitorum, and to a slight extent the muscles inserted in the tendo Achillis. The tibialis antieus, beside flexing, inverts the foot somewhat, as it runs slightly inward from the oblique axis through the head of the astragalus. The extensors also invert slightly. The muscles to the outer side of the axis abduct and evert; the peronei most actively, the extensor digitorum less so. If the dorsum of the foot is examined while the foot and toes are flexed strongly, it will be seen that the tendon of the extensor loneus hallucis becomes prominent to the inner side of the middle of the ankle (Fig. 449); further to the inner side the tendon of the tibialis antieus diverges from it toward the inner border of the foot; to the outer side of the extensor hallucis the tendons of the extensor communis digitorum radiate to the second, third, fourth, and fifth toes; further out is the tendon of the peroneus tertius running to about the middle of the outer border of the foot. Below the ankle the dorsal artery of the foot can be felt between the tendon of the extensor longus hallucis and the first tendon of the extensor longus digitorum. The lateral margins of the upper articular surface of the astragalus can be felt between the tendons, and the malleoli if the foot is extended strongly, but disappear in flexion. Beneath the external malleolus the calcaneum can be felt, and below the internal, the prominent sustentaculum The tuberosity of the scaphoid is palpable beneath the skin about a thumb's breadth in front of the anterior border of the malleolus on the inner side of the foot; the head of the astragalus lies deeply situated behind it. The base of the first meta- tarsal lies 1 1 inches in front of the scaphoid ; the first cuneiform between them cannot be felt distinctly. On the outer border of the foot the base of the fifth metatarsal projects at about the middle. The bases of the first and fifth metatarsals give the position of Lisfranc's joint; the line of Chopart's joint lies close behind the tuberosity of the scaphoid. Vol. III.— 46 CHAPTER XXXYI. CONGENITAL MALFORMATIONS OF THE FOOT (EXCEPT CON- GENITAL CONTRACTURES). Congenital hypertrophy may affect the entire body, one side, one or both extremities, or only portions of the same. It is of little importance except where it affects only the lower extremities, and especially one. It is more frequently limited to parts of the extremity and as a rule the peripheral, than diffuse. In general it is apparently more rare in the lower than in the upper extremity. True hypertrophy affects all the tissues equally; in false hypertrophy the increased size of the limb is due to moderate growth of one particular tissue. True hypertrophy of the entire limb is very rare, but of parts of the limb, and generally of the distal portions of the same, somewhat more frequent. (Fig. 450.) The Fig. 4.50. Fig. 451. Congenital hypertrophy of the second toe. Child eleven years old. (v. Bergmann's clinic.) Hypertrophy in the foot. Supernumerary digits. (WittelsfaWer.J cases of false hypertrophy are much more numerous. Hypertrophy solely or chiefly of the skeleton is practically unknown. In connection with diffuse or circumscribed hypertrophy of the soft parts, the bones may be enlarged, normal, or even atrophic; in the latter case the con- dition approaches the congenital forms of elephantiasis, or, if the hyper- trophy is circumscribed, the congenital tumors. Hypertrophy of the adipose tissue is the most common form, either diffuse over the entire limb or localized, preferably in the toes and foot. (Fig. 451.) Com- binations of hypertrophy with other malformations, especially syndac- tvlia, are not infrequent. All forms of hypertrophy are accompanied rather often by changes in the vascular system, either congenital, such (722) CONGENITAL MALFORMATIONS OF THE FOOT. 72;; as nee v us vasculosus, telangiectasis, or acquired, as, for example, phlebectasis. As to the changes in the nerves in the bypertrophied limb: Fischer claims to have found decreased sensibility in the hypertroph ied part; Wagner saw a painless mal perforant. Increased ephidrosis and sensitiveness to cold of the affected parts are also reported rather fre- quently. All these disturbances may be of a secondary nature and due to circulatory changes, neuritis, etc., but their similarity to the anomalies of the nervous system demonstrated in acromegaly is striking and deserves further study. Abnormal pigmentation, resembling that found with multiple neurofibromata, is also seen in all cases of hyper- trophy. Such multiple nsevi not infrequently represent trophoneurotic disturbances; similarly multiple lipomata, and particularly diffuse lipoma, have been referred to nervous disturbances the nature of which is still obscure. Anatomical changes in the nerves have never been reported, however, either in true or false hypertrophy; the cases of neuritis nodosa were apparently elephantiasis neuromatodes, or flexi- form fibroneuromata. The etiology of congenital hypertrophy is quite unknown. The further development of the hypertrophy apparently varies according to its nature; in some instances it keeps pace with the growth of the body, in others it is more rapid. Usually it remains limited to the parts first attacked, and only rarely spreads progressively upward through the entire extremity. In false hypertrophy the growth of the affected parts is apparently more rapid than that of the rest of the body, occasionally becoming more rapid after being stationary at first. A permanent arrestment has never been seen. Surgical treatment is necessary only if the function of the limb is impaired. Resection or excision of the epiphyseal cartilage is of little use except in favorable cases. As a rule amputation or exarticulation is necessary. By these operations the hypertrophies of the toes which are stationary or growing at the rate of the body can be overcome. But if the entire extremity is involved or the growth advances rapidly upward, the process cannot be checked even by early operation, as shown in a case of Fischer's of rapid hypertrophy of the arm. Operation is more often necessary in the case of false hypertrophy accompanied by the formation of tumors in the soft parts; even here the removal must be thorough to effect a permanent cure. If the growth is large and diffuse, or if the bone is greatly involved, amputation must be well above the disease as in the case of other neoplasms. Occasionally, however, a permanent cure is impossible if there are lipomata on the trunk (Fischer) or general corpulence develops (Billroth under Wittelshofer). Xon-opera- tive measures, of which compression with simple or elastic bandages has been tried the most, have never been successful. Even in the cases of telangiectasis or lymphangiectasis they were only palliative. Con- genital elephantiasis cannot be distinguished sharply from false hyper- trophy; it is less frequently limited to the foot, and is usually more extensive. Acquired elephantiasis is as a rule a local manifestation of 724 CONGENITAL MALFORMATIONS OF THE FOOT. disease involving the entire limb to a varying extent (see corresponding section). Supernumerary digits are somewhat more common than hypertrophy, but less frequent than the same anomalies in the upper extremity. The Fig. 452. Supernumerary small toe. (v. Bruns' clinic.) changes are the same as those in polydactylia in the upper extremity, to the description of which the reader is referred. Eleven toes on each foot is the greatest number seen thus far. Seven to nine are more fre- Fig. 453. Supernumerary toe. (v. Bruns' clinic.) quent and six most frequent. (Figs. 452 and 453.) In the case of one or two supernumerary digits, they are almost always on the inner or outer side, rarely in the middle of the foot. The coexistence of CONGENITAL MALFORMATIONS OF THE FOOT. 725 supernumerary fingers and toes has been recorded by Vogt, also an heredity through several generations. It is significant thai where there is an extra toe on the first or fifth toe, as a rule only the phalanges arc developed, analogous to the relations in the hand, while the meta- tarsal is lacking. According to Forster, in reduplication of the other toes — or fingers — not only the phalanges are double, but also frequently the metatarsals and bones of the tarsus. Combinations of polydactylia and syndactylia occur the same as in the hand. (Fig. 454.) Authors still disagree as to the genesis of polydactylia; some (K. Bar- deleben) assume atavism as the cause, analogous to the primitive penta- dactylic and heptadactylic forms in mammals; others (Gegenbauer) regard it as a malformation in the strictest sense, due to disturbance in the primitive trace. In the majority of cases it must be referred to external causes (trauma), especially constriction by amniotic bands, as verified by an observation of Ahlfeld of an amniotic thread attached Fig. 454. Polydactylia and syndactylia. (Heynold.) at the point of cleavage of a cleft thumb. The same methods and rules of operation apply as in the case of the fingers. A case of macrodactylia, namely, an hypertrophied hallux with three members, is reported by Hallmann. Deficiency, the antithesis of hypertrophy, may be manifested as brachydaetylia or microdactylia; the two conditions can exist simul- taneously in the same toe or in several toes. There may be complete absence of one or all toes, ectrodactylia, in which case the bones of the tarsus, metatarsus, the leg, or even the thigh, are frequently defective. In addition to the defects there are frequently adhesions, syndactylia, and exceptionally supernumerary digits, polydactylia. Many of these defects are irregular in form and extent and unquestionably due to amniotic adhesions or bands, constriction by the umbilical cord, etc. The evidence of such causes is not infrequently found, amniotic threads, cicatrices, grooves, and in ectrodactylia, a peculiar conical stump due to amputation. At the same time syndactylia and contractures, such as 726 CONGENITAL MALFORMATIONS OF THE FOOT. pes varus, valgus, etc. Other defects show a certain regularity and symmetry, and are associated with analogous defects in the hands. Most frequently one or even three of the middle toes are absent if the defect does not extend beyond the tarsus. If all three are absent, the middle metatarsals or even the tarsals may be absent or rudimentary. The foot then appears cleft into the tarsus (Figs. 455 and 456), and resembles the same condition in the hand, which has been com- pared to a lobster claw. These malformations are also hereditary. Absence of the marginal toes alone is rare, but in combination with defects of the bones of the leg is very common. Many of these deformi- ties, in which there is undoubtedly a certain amount of uniformity, can be referred to injurious external influences. The symmetry does not posi- tively exclude such causes, as the latter can affect symmetrical parts of the body and arrest their development (for example, a small amnion, pressure Fig. 455. Fig. 456. Ectrodactylia, with forking of the tarsus. (Pott.) of the uterus due to lack of amniotic fluid, etc.). But it is hardly pos- sible to refer defects associated with a distinct heredity to adventitious external influences. Such cases suggest faulty construction of the primitive trace. In accord with Wiedersheim, Goldmann represents the development of the foot as follows: At a certain stage the tarsus consists of three parallel rays of tissue, each divided into several seg- ments (the tarsal bones), the tibial and medial rays later forming the first two toes. From the fibular ray, which is derived secondarily from the fibula, are formed branches representing the fourth and fifth toes, and the basal element of the third toe from which the third toe is derived. The first two rays are to be regarded as primary rays. The first of these develops into the tibia and the hallux, the second into the fibula and second toe, while the other toes are to be regarded as secondary offshoots of the two primary rays, with the exception that the fourth and fifth toes are branches of the secondary ray which develops into the CONGENITAL MALFORMATIONS OF THE Four. 727 third toe. This theory would explain why defects of the tibia are so apt to be accompanied by absence of the hallux, and why with defects of the fibula the four outer toes arc partially or completely lacking; but it does not explain why the fifth toe, the last offshoot of the fibular ray, is so constant, that it is present with the hallux in the absence of all the other fibular branches, or even occurs alone in the absence of all the other toes, (ioldmann tried to explain the absence of the middle toes by external conditions, pressure of the uterus; aside from the fact that it is difficult to understand this on mechanical grounds, there is the further objection against Goldmann's view, that these defects are fre- quently symmetrical in the hands and feet and that they are inherited. In general, deficiencies rarely require surgical treatment except for the accompanying contractures, syndactylia or polydactylia. Syndactylia occurs in the toes to the same extent that it is seen in the fingers. The middle and the outer toes are the ones most frequently fused together; in the cases reported the great toe is adherent less often to the other toes than the thumb is to the index finger. The failure of the skin to separate between the toes may be due to the external causes mentioned, although it is probably referable to faulty embryonal con- struction, for here also symmetry and heredity are important factors. Operative treatment is the same as for the hands and as described by Vogt, except that skin-grafting is more frequently employed at the present time to cover in the resulting defects. Operation is only excep- tionally indicated, however, as the foot even with one or all toes adherent is useful unless other deformities exist. Defects and fusion of the tarsals occur without corresponding mal- formations of the toes, but are only of surgical interest if followed by contractures and faulty position of the foot. CHAPTER XXXVII. INJURIES OF THE ANKLE AND FOOT. SPRAINS OF THE ANKLE-JOINT. A SPRAIN, namely, stretching and partial laceration of the ligaments, is frequently the result when the various forms of violence which ordi- narily produce fracture and dislocation are applied with less intensity or are more quickly exhausted. It is a very common injury, and may be divided into two groups, sprain by eversion and by inversion, the former being less frequent than the latter (see p. 718, ff). In sprains by eversion the foot is usually also rotated outward at the tip and flexed, corresponding to the physiological movements, and in those by inversion, also rotated inward and extended (plantar-flexion ). The ligaments on the plantar and inner surface of the foot are very strong, so that forced eversion or outward rotation is more apt to fracture the malleolus than to tear the ligaments. On the contrary, sprain is an extremely common result if the foot is twisted inward. If this happens without much inward rotation of the tip of the foDt (adduction), the calcaneo-astraga- loid ligaments and those below and in front of the external malleolus and on the dorsal outer surface of the astragaloscaphoid joint are torn. The most frequent site of tenderness and ecchymosis is therefore below and in front of the external malleolus. On the other hand, if inward rotation (adduction) of the foot predominates, the joints between the calcaneum and cuboid and between the scaphoid and cuneiforms are more often contused; the ecchymosis is then farther forward. The diagnosis is made by the tenderness, ecchymosis, and the absence of fracture of the malleoli or of the tarsal bones. Larger effusions of blood are apt to fill or surround the ankle-joint and conceal fractures of the malleoli or avulsion of small fragments of bone. So that in the absence of displace- ment, such fractures are very often overlooked and treated as sprains. Therefore in all doubtful cases the injury should be treated as a fracture. Treatment. — Massage has been properly recommended to remove the effusion of the blood in slight sprains; the patient may be allowed to go about wearing a supporting and compressing bandage. Gibney's adhesive plaster dressing is well recommended for ambulant treatment (Fig. 457), but is advisable only for slight injuries. In severe cases of sprain, in which extensive laceration of the ligaments is suspected from the marked extravasation, we consider it best to immobilize the foot in a strip (see Fig. 466, p. 740), or plaster-of-Paris-splint for two to two and a half weeks; later massage and active and passive motion are carried out. ^Ye prefer this method to the use of ice-bags and massage, so frequently employed to limit or remove extravasation, because it insures the firmest union of the torn ligaments. In simple sprains (728) INJURIES OF THE TENDONS. 729 the fixation does not produce serious stiffness, and without fixation the repair of the ligaments is only partial. In the latter case the result is weakness of the ligaments and an instability of the foot which leads to Fig. 457. ■ - - - Gibney's adhesive plaster dressing. frequent recurrence. This explains many habitual sprains. On the other hand, under appropriate treatment a sprain should recover without leaving any functional disturbance. INJURIES OF THE TENDONS. Dislocation of the Tendons of the Foot. — At the point where the tendons of the peroneal muscles pass under the outer malleolus they are retained in a deep groove by two strong bands, the retinaculum superius and inferius. The upper transverse fibres represent part of the fascia of the leg, the lower band forms a loop attached to the cal- caneum. If these are torn, the tendons may be displaced to an extent corresponding to the severity of the tear. This rather rare injury is usually due to violent contraction of the muscles of the calf in the effort to prevent the foot, twisted inward, as in jumping, from being twisted further, the tendons being torn from the grooves by the sudden forcible abduction and plantar flexion of the foot. The foot is disabled; the outer malleolus appears to be thickened; the tendons can be rolled about beneath the finger. If only one tendon is displaced, it is commonly 730 INJURIES OF THE ANKLE AND FOOT. the peroneus Longus. Usually the tendons are easily reducible, often slipping back with a snap, but become reluxated if the foot is abducted. Treatment. — The treatment consists in replacing the tendons, apply- ing a graduated compress, and over this a bandage; or, adhesive plaster strips are applied over and parallel to the tendons. The foot is then immobilized, preferably in slight inversion. Many cases recover in this way; in others, in spite of protracted treatment, the tendons slip out of place; in recent cases the torn bands may be sutured back in place with catgut. If the dislocation becomes old or habitual, locomotion becomes hampered and unsteady, the slipping back and forth of the tendons being very annoying. Of the various operations proposed, those of Konig and Kraske have been most successful: A flap of bone and peri- osteum is turned down and over the tendons so that the periosteum lies against them and is then sutured to the bone behind them. The same dislocation occurs as a complication of fracture and requires appropriate treatment. Martins reports a dislocation of the tendon of the tibialis posticus forward in front of the inner malleolus; reduction and retention were simple and were followed eventually by complete recovery although the foot was disabled for some time afterward. Laceration of the Tendons of the Foot.— The tendo Achillis is some- times torn by the action of violence similar to that which produces fractures of the tuberosity of the calcaneum. Often the tear is only partial; but the gap between the separated stumps, the swelling about the tear, and the loss of function are diagnostic. Recovery is by fibrous union, similar to that which forms after tenotomy. If the stumps are separated to any extent or the sheath torn, the long fibrous cicatrix which forms is inadequate, so that the strength of the muscles of the calf is greatly reduced. We have seen numerous such cases. If the tendon is completely divided by an open wound, the stumps are usually sepa- rated widely and become adherent to the sheath at the level of retraction without any fibrous union forming between. If the wound is infected the inflammation may extend up to the calf. Subcutaneous laceration of the other tendons is not known, except a case of the plantaris longus which was followed by complete recovery. Open division is frequent. Treatment. — In case of subcutaneous laceration with slight separa- tion one may attempt to approximate the stumps by flexing the knee and extending the foot and immobilizing the limb in this position for two to three weeks with a posterior or circular plaster-splint; later, passive motion is begun but active motion not for some time, as the fibrous bridge between the stumps is easily stretched. We saw a case of a jumper (a. clown | in whom the function was completely restored in this manner. If the stumps are widely separated, they may be sutured together. In v. Bergmann's clinic this was done successfully in the case of a circus-rider, but was extremely difficult on account of the fraying out of the stumps. Open division requires suture under strict antisepsis; a splint is applied in the same way as for subcutaneous FRACTURES ABOVE THE MALLEOLI. 731 laceration. If the tendon has united by a long fibrous bridge, the stumps should be exposed, freshened up, and sutured while the knee is held flexed and foot extended. The operation has been successful repeatedly. The treatment of open division of the other tendons is on general principles. Laceration of the plantar fascia has been seen associated with frac- tures of the malleoli and other injuries of the foot ; in a number of eases the resulting fibrous union was excessive in the form of nodules which persisted for months or years; usually the nodules disappeared spon- taneously but with a resulting contraction of the fascia, analogous to Dupuytren's contraction of the palmar fascia. Ledderhose studied the process closely and found that the nodules appeared mostly after immo- bilizing splints had been worn and during the first attempts at walking. He is inclined to regard it as an atrophic disturbance in the fascia due to laceration, the action of the splint, etc.; a reactionary proliferation of the fascia follows, analogous to that known to occur in other tissues; the fascia, as a result of this "fasciitis chronica," is less resistant, is easily ruptured, and heals by excessive nodular cicatrices. In a few cases the nodules were so troublesome in walking that he was obliged to excise them. FRACTURES ABOVE THE MALLEOLI. Those fractures are termed supramalleolar (Malgaigne) which are situated from * to 1 inch above the line of the tibiotarsal joint; as a rule Fig. 458. Fig. 459. Supramalleolar fracture with partial separation oi the epiphysis combined with oblique lracture 01 the tibia, (v. Bruns' clinic.) 732 INJURIES OF THE ANKLE AND FOOT. Fig. 460. they involve the joint. They may be due to direct violence, such as run-over accidents, etc., but are more frequently caused by falling from a height, the foot at the same time being twisted inward or outward. The astragalus thus wedges the malleoli apart. Exceptionally there is merely laceration of the tibiofibular ligaments and the bones become separated; but usually there is a longitudinal fracture of the tibia along its outer margin. If the force is continued, the tibia may be broken by inflexion close above the joint. This happens more frequently by adduction than by abduction of the foot. Tillaux produced the frac- ture experimentally by forced adduction, and believes that after the fibula has yielded in the lower third the inferior tibiofibular ligaments pull on the tibia so that the latter is broken on its outer side by avulsion and on the inner side by inflexion. As a matter of fact supramalleolar fracture occurs most frequently if the foot is everted by the fall. The same mechanism is caused by a false step, in that with the foot fixed the weight of the body breaks the obliquely directed leg above the malleoli. (Konig, Reinhardt.) The fracture-line varies greatly. (Fig. 458 to Fig. 400.) It may be transverse through both bones, or irregularly ser- rated ; often a fragment of the articular surface of the tibia is torn off behind or in front. As stated, a longitudinal frag- ment may be torn from the outer sur- face of the tibia. The lower fragments of the tibia and fibula are frequently broken into several pieces; the upper fragment of the tibia may become im- pacted in the lower or slip down beyond it and impinge against the os calcis. Symptoms. — The symptoms are very irregular. If the fragments are merely displaced laterally, the ankle is broad- ened; in other instances the foot is twisted sideways, most frequently everted, so that the condition may resemble a lateral dislocation, but the bony prominence above the line of the joint on the convex side is diagnostic. Or the tibia and fibula may be separated and the foot become displaced upward in the interosseous space, or back- ward and upward with the upper fragment of the tibia lying on the front of the astragalus and so resembling backward dislocation of the foot. Diagnosis. — The diagnosis may be difficult as the swelling is usually pronounced. Careful palpation is therefore necessary. As this is painful, an accurate coaptation of the fragments is difficult. Hence, anaesthesia is usually desirable. Supramalleolar fracture. Union with deformity. (v. Bruns.) FRACTURES OF THE MALLEOLI. 7:;:j Prognosis. — The prognosis is unfavorable. As a rule the period of recovery extends over three months, and a definite decision as to the usefulness of the foot is frequently impossible within a year. Deformity and impaired motion, or even ankylosis, are frequent. Treatment.— The treatment is the same as that of fractures of the malleoli. FRACTURES OF THE MALLEOLI (POTT'S FRACTURE). Fractures of the malleoli are the most frequent fractures of the leg next to those of the shaft of both bones of the leg. In the large majority of cases they are due to indirect violence; exceptionally to direct violence, such as a blow or fall upon the inner or outer side of the leg. Mechanism. — In their mechanism of origin indirect fractures of the malleoli cannot be distinguished from sprains or lateral dislocations of the ankle-joint. All these injuries are produced by twisting of the foot upon uneven ground, or by falling sideways while the foot is fixed, for example in a hole, railroad track or between rocks, or by violent rotation of the leg while the foot is fixed, or by the foot being everted or inverted forcibly against the ground in jumping or falling. The effect is there- fore essentially an exaggeration of the physiological movements of the tibiotarsal joint, either inversion or eversion — that is, rotation about the long axis of the foot, or abduction or adduction, namely, rotation about an imaginary vertical axis through the leg. That as a rule the tibiotarsal joint rather than the mediotarsal joint is injured by these movements is due to the fact that owing to the strength of the ligaments of the mediotarsal joint and to the contraction of the muscles at the moment of injury the foot transmits the force like a stiff lever-arm to the tibiotarsal joint. If the force is quickly spent, it merely produces laceration or partial rupture of the ligaments — that is, a sprain; but if it acts more energetically, the ligaments usually prove more resistant than the bone, so the latter is fractured by avulsion on the side of the convex- ity, namely, by eversion a fragment of the tibia is torn off and by inversion of the fibula (fracture par arrachement). In addition, however, another factor comes into play. The astragalus is rotated violently at the same time and so wedges the tibia and fibula apart with rupture of the inter- osseous ligament or forces off one of the malleoli (fracture par divulsion). In fractures of the malleoli these two forces, pressure and traction, are usually combined. If the force is continued after the fracture has been produced, the astragalus becomes dislocated laterally. There is there- fore a lateral dislocation of the foot, a thing which happens very seldom — as can be understood from the above considerations — without fracture of the malleoli. The difference between fractures of the malleoli and lateral dislocations of the foot is merely one of degree, hence the rather appropriate term "dislocation fractures." (Stromeyer.) For a long time experiments have been made on the cadaver to deter- mine the mechanism of fractures of the malleoli. (Dupuytren, Maison- 734 INJURIES OF THE ANKLE AND FOOT. neuve, Bonnet, Tillaux, Honigschmied.) Forcible eversion and inversion of the foot, namely, rotation about its long axis, was termed fibular flexion and tibial flexion by many authors, as applied to the transmission of these movements to the tibiotarsal joint. The foot was also forcibly adducted and abducted — that is, rotated about a vertical axis through the leg. It was thus sought to demonstrate which move- ments in the tibiotarsal joint produced the various forms of fracture. In the living subject these forces do not act separately, however, but rather adduction and inversion (supination) and abduction and eversion (pronation) are usually combined, corresponding to the physiological movements of the tibiotarsal joint. We distinguish, accordingly, adduction or inversion fractures and abduction or eversion fractures. [The author classifies as inversion or eversion fractures those in which the dominant force is violent adduction or abduction, corresponding to our adduction and abduction fractures.] Fractures by Inversion and by Adduction. — If while the foot is fixed the body falls to the tibial side, or if the foot is twisted inward by a misstep or in jumping, or if while the leg is fixed the foot is driven violently inward and upward, the tibiofibular and external lateral ligaments are put upon the stretch and the latter tears the external malleolus off at or above its point of insertion if it is stronger than the bone; the result is a transverse or slightly oblique fracture about f inch above the tip of the malleolus. If the force is continued, the astragalus is driven inward against the internal malleolus and breaks it partly or completely off; if the fragment becomes displaced, the foot stands in the varus position. The symptoms of this fracture are not usually pronounced. If only the fibula is broken, the break is often an infraction without displace- ment, false motion, or crepitus, the only sign being a fixed point of tenderness on the malleolus. There is an effusion of blood in the joint. The patient is often able to walk. The fracture is therefore not infre- quently mistaken for simple sprain. On the other hand, if the peri- osteum of the fibula is torn through completely, the edges of the frag- ments and the groove between them can be felt and crepitus and false motion usually elicited. In the same manner fracture of the internal malleolus may be without any displacement and only evidenced by a localized point of tenderness. If the force rotates the foot principally inward about the vertical axis of the leg, there may be merely a sprain with laceration of the external lateral ligament and the ligaments of Chopart's joint; or there may be a fracture of the fibula above the external lateral ligament, or a torsion fracture of the tibia and fibula due to rotation of the astragalus. These adduction fractures (the author's "inversion fractures") are rare. In all the forms of inversion and adduction fractures the displacement is rarely marked unless the ligaments are extensively torn; the foot is then adducted; the astragalus is twisted so that the trochlea faces the external malleolus and its under surface faces inward. It is therefore dislocated. Displacement in a horizontal direction is less frequent. Fll.UJTURES OF THE MALLEOLI, 735 Fractures by Eversion and by Abduction.— These forms are much less frequent than the above, and are produced similarly but in the opposite direction by violent eversion or abduction of the foot. If, for example, the entire foot is held firmly while the body falls outward, the deltoid ligament is put on the stretch; it is rarely torn, bul usually tears off the internal malleolus, and as a rule near its base; exceptionally the ligament is torn off at its insertion on the astragalus. The force continued drives the calcaneum against the tip of the external malleolus; the latter may be crushed. The mechanism is commonly a different one, however; while the astragalus and calcaneum press the external malleolus outward, the weight of the body forces the leg and the shaft of the fibula Fig 4fil Fig. 462. Typical eversion fracture of the malleoli, (v. Bruns.) Fracture-lines of avulsion fractures of the outer part of tibia, with fracture of internal malleolus. Diagrammatic, (v. Volkmann.) inward. The entire weight of the body thus rests upon the fibula as it impinges against the calcaneum and the fibula breaks at its weakest point above the tibiofibular ligaments, namely, 2 to 2[ inches from the tip. The typical form of this fracture by eversion is therefore a tear- fracture of the internal malleolus and secondary inflexion fracture of the fibula above the joint (typical Pott's fracture). (Fig. 461.) By this mechanism the tibiofibular ligaments are always stretched to the utmost whether the typical fracture occurs or not. These ligaments may give way, the tibia and fibula may be pushed apart — diastasis — and the astragalus become wedged between the bones in the interos- seous space; or if the ligaments are stronger than the bone the external malleolus, pressed upward and outward, may tear off a fragment from 736 INJURIES OF THE ANKLE AND FOOT. Fig. 463. the tibia, (v. Volkmann.) (Fig. 462.) If the injury results from falling from a height, the direct pressure of the <\--;agalus is unquestionably concerned in breaking off the fragment t .*.. the outer border of the tibia. The fracture-line in the tibia is usually very oblique from above downward and inward; the base of the wedge-shaped fragment may be very small or include the entire articular surface of the tibia. According to the degree of violence, the fragments may be only slightly displaced and the foot stand approximately in its normal position; or the astragalus may be rotated on its sagittal axis till the trochlea faces the internal malleo- lus, the so-called outward dislocation of the foot. Exceptionally the astragalus is dislo- cated horizontally at the same time. In those very severe cases of dislocation the skin is stretched tightly over the internal malleolus and may give way or be transfixed by the upper fragment of the tibia. (Fig. 463.) In many instances the violence acts less in the sense of everting; the astragalus and cal- caneum than in abducting or rotating the tip of the foot outward (eversion fracture of the author). For example, if the foot is fixed or wedged and the body and leg are rotated in- ward while falling, or when a rider hangs by the stirrup, or if while in the saddle his foot is twisted backward by striking a tree or wall. In all these instances, as the tarsal joints are fixed, the foot represents a lever perpendicular to the malleoli, which it forces apart. The internal malleolus is thus pressed forward and inward by the inner surface of the astragalus and the outer malleolus is pressed outward and back- ward by the outer surface, usually followed by fracture of the fibula. The fracture begins w T ith the tearing off of a triangular fragment from the lower end of the tibia, corresponding to the attachment of the anterior tibiofibular ligament, the force is continued from in front and to the inner side upward and outward through the fibula, so that the fibula is broken off at a higher level than the tibia, the lower fragment ending behind and to the inner side in a sharp point. The lower fragments may be displaced outward with the foot so that the trochlea of the astragalus comes to lie below the upper fragment of the fibula. Less frequently only the tip or the posterior part of the external malleolus is torn off by the posterior fasciculus of the external lateral ligament. The displacement of the fragments in these abduction fractures, and Eversion fracture with marked dislocation and laceration of the skin under the internal mal- leolus. (Anger.) FRACTURES OF THE MALLEOLI. 737 thereby the displacement <>l" the astragalus, may be such that the astrag- alus is rotated outward 9(7 degrees on its vertical axis and the foot points outward; this typa of dislocation has been termed outward rotation-dislocation. Symptoms. — The symptoms of all these abduction and (version fractures are obviously very diverse. A characteristic picture can be drawn only for the typical eversion fracture, the elements of which are a tear-fracture of the internal malleolus and a supramalleolar fracture of the fibula. Usually the foot is distinctly, although only slightly, abducted and everted, namely, in the valgus position. The prolonga- tion of the axis of the tibia which ordinarily passes between the first and second toes, falls to the inner side of the foot; this deviation may be due either to abduction or to eversion of the foot as a unit. The upper frag- ment of the tibia projecting beneath the skin makes the region of the internal malleolus more prominent. The malleoli appear broadened in consequence of the outward displacement of the external malleolus. On the outer side of the leg above the joint there is an angular deformity corresponding to the fracture of the fibula. The deformity is readily increased by manipulation and also becomes more marked if the patient attempts to walk. All these symptoms may be wanting in the absence of displacement, the only evidence of fracture being the functional loss and extravasation of blood. The latter is greater than in simple sprain; it extends along the tibia and fibula, and almost always fills the joint, which happens less frequently in sprain. An extravasation of any amount at both malleoli should always suggest fracture. A positive diagnosis is only possible, however, by careful palpation except with displacement; by following down the surface of the bones from above a localized point of tenderness is found at the site of fracture. On the tibia, in the absence of much swelling, a grooved depression can be felt above the tip of the malleolus, and often the fragment can be seized and shifted. On the fibula the upper fragment, pointed and projecting somewhat, can sometimes be felt. Palpation is facilitated by pressing the extravasate aside gently; but as this is often painful it may be impossible without anaesthesia. If the lower fragment is not too large, sometimes it can be rocked under the fingers upon the edge of the astragalus. In many instances crepitus and false motion can be elicited by lateral movements of the fragment unless the manipulation is too painful or hindered by swelling. In the latter case the diagnosis depends upon the localized point of tenderness; hence the importance of knowing the typical lines of fracture. Hiiter has called attention to the pain produced by flexing the foot forcibly, due to the fragments being wedged apart by the broader front part of the astragalus. E. Rotter showed that pain could be elicited at the point of fracture by pressing the tibia and fibula together higher up. Wagstaffe (1875) and Le Fort (1886) described a peculiar form of fracture of the external malleolus, a tear-fracture, produced by violent adduction or abduction of the foot, in which a vertical plate w r as torn from the anterior surface of the external malleolus by the anterior tibio- Vol. III.— 47 738 INJURIES OF THE ANKLE AND FOOT. fibular ligament. It is apparently more common than was formerly supposed. (Ricard.) The extravasation is less than in typical fracture of the malleolus; the point of tenderness corresponds to the site of fracture. Pressing the tibia and fibula together is painless. A few cases are reported in which, in addition to other injuries of the tibia and fibula, a flat plate of bone was broken off at the front sur- face of the tibia close above the joint, with base below of the width of the tibia and tapering upward (Volkmann, Lauenstein); the fragment was apparently broken off by the pressure of the front of the trochlea against the neck of the astragalus during sudden forcible flexion or inversion of the foot (Lauenstein). Separation of the lower epiphysis of the tibia occurs up to the twen- tieth year, and is a rather frequent injury (compare Figs. 458 and 459). It may be complete or incomplete. Displacement is often very slight. The diagnosis is made from the age of the patient, the increased breadth of the tibia, pressure tenderness corresponding to the epiphyseal line, and cartilaginous crepitus. The treatment consists in reducing by direct pressure and immobilizing the foot as in malleolar fracture. Diagnosis. — If the above symptoms are properly considered the diagnosis of typical malleolar or supramalleolar fracture is always possible; that of incomplete fractures, infraction, lamellar fractures, atypical malleolar or supramalleolar fractures, is more difficult and occasionally impossible even under ana?sthesia. Infraction and lamel- lar fracture can usually be detected with the .r-ray. In fact, the .r-ray is of inestimable value for all severe atypical fractures if two views are taken, namely, from the side and front, to prevent deception. Treatment. — The prognosis depends largely upon the treatment. If the latter is appropriate, even severe cases may recover fully without functional disturbance. From more recent statistics it would appear that a certain amount of impairment persists in about one-fourth of the cases. Reduction is effected by grasping the heel and dorsum with the hands and making traction upon the foot while the leg is held firmly. Any lateral or forward or backward displacement is then determined by comparing with the other foot. The position of the front part of the foot is of less importance than the correction of any lateral displacement or rotation of the astragalus and calcaneum. The mistake is often made in an eversion fracture with outward dislocation of the tarsals of inverting the foot in Chopart's joint without correcting the inflexion of the malleoli and the lateral displacement of the tarsals; the result is a pes valgus. Usually the foot may be immobilized in its normal position, namely, at a right angle to the axis of the leg; in severe cases the proper position of the tarsals and the malleolar fragments is best in- sured by immobilizing the foot in slight inversion. A circular plaster-splint is the best for holding the reduced foot in position. If applied immediately after the injury, it should be well padded to avoid the dangers contingent upon swelling. It should be renewed at the end of eight or ten days to meet the looseness resulting from the subsidence of the swelling and flattening of the padding. Any FRACTURES OF THE MALLEOLI. 7.39 intercurrent displacement should also be overcome, If necessary under anaesthesia. In mild cases, for example fractures of the fibula, the second splint may be worn till union is sufficiently firm to allow of massage and motion in the joint without danger of producing displace- ment, namely, in about three weeks. Even in the mildest cases, how- ever, the patient should not walk after this without wearing a supporting .splint or apparatus. In severe cases it is well to change the second splint at the end of fourteen days, to massage and move the foot care- fully and apply a new splint to be worn for about three weeks; then massage again, and passive movements of the joint. The splint may be removed earlier, but should be reapplied each time, after massage. In the last weeks of treatment the patient may go about on crutches but without stepping on the foot. The weight should not be placed on the foot till the end of the seventh or eighth week in severe cases, as the Fig. 464. Dupuytren's splint for abduction fractures of the malleoli. callus yields readily and may result in a faulty position of the foot. The older and heavier the patient, the later and more cautiously should the foot be encumbered. Too early use is often responsible for a later faulty position of the foot. Many surgeons disapprove of applying the plaster-splint immediately after injury and advise immobilization in a Volkmann splint for the first few weeks. This is quite proper if the foot cannot be inspected daily, but if it is under constant observation, a well-padded plaster-splint is unobjectionable and preferable, as it insures better immobilization. Instead of this strip splints may be used. (Figs. 466 and 467.) A simple dressing such as the one suggested by Dupuytren for abduction fracture is also well spoken of (Fig. 464); it may be valuable in an emergency, but it is not advisable for longer applicaton. Ambulant treatment with the so-called portable apparatus has been widely recommended. We admit that the experienced are in a position : 40 INJ CRIES OF THE ANKLE AND FOOT. to treat slight fractures without any difficulty, and even severe fractures without loss, by this method. But in general the surgeon should be warned against this mode of treatment, as displacement occurs only too easily if the splint does not fit accurately or is not solid. We have seen many a case of pes valgus produced in this way. Excellent results have Fig. 466. Fig. 407. Stimson's outer and posterior moulded plaster-of-Paris strip splint? for fractures about the ankle- joint; applied over. flannel strips (see page 296;, bandaged with light gauze roll bandage, the foot held by hand or Band-bags until the plaster hardens, gauze bandage then removed, adhesive- plaster strips applied as shown, and the whole bandaged with muslin rolls. Outer strip may extend to head of fibula, if desirable; posterior strip should not encroach upon the popliteal space or thigh during flexion. (Solley.) also been obtained by means of various extension splints and apparatus, especially by Bardenheuer, but these appliances require special expe- rience and care. Bardenheuer applies broad strips of heavy adhesive plaster (Segelfuchheftpflaster) on both sides of the leg and fastens them together under the sole so that they exert pressure against the malleoli. FRACT URES OF Til E MALLEOLI. 7 4 1 Outward cross-traction is applied above the malleoli to draw the bones of the leg outward and overcome the pes valgus. The pes equinus position and backward dislocation of the fool are corrected by vertical extension fastened to the foot. In conclusion, the chief points in the treatment are accurate reduc- tion of the fragments, absolute control, and finally improvement of the position of the foot after the swelling of the joint has subsided. Upon this depends largely the later usefulness of the limb. Secondarily the mobility of the joint has to he thought of. Immobilization should not be continued too long, hut massage and passive motion begun as soon as the danger of displacement is past. The weight of the body should not be placed upon the toot without wearing a supporting splint or apparatus, and even then not until the sixth week; in severe cases the eighth week. Later, massage, especially of the muscles of the leg, and exercises are very important. The period of recovery is longer than was formerly supposed. In the mildest cases — infraction of the fibula — the patient is often able to work in seven or eight weeks. Other- wise, in mild cases light work is usually not resumed till two or three months and heavy work in about five months; in the case of severe fractures these periods become three to four and four to eight months, respectively, or even longer. The long duration of recovery depends largely upon the stiffness and painfulness of the joint, the firm oedema which is apt to occur, and the weakness of the muscles of the leg due to the long fixation. For this reason great care should be exercised in placing the full weight of the body on the foot. The causes of per- manent damage are chiefly faulty position of the fragments and of the foot. Especially significant in this respect is the lateral displacement and rotation, the pes valgus position, which follows eversion fractures. This can be prevented. But the disturbances due to deformation of the joint following comminuted fractures, or marked separation of the tibia and fibula with avulsion of fragments, are often unavoidable. Some of the articles published during the last year with reference to accident legislation fin Germany) give valuable information in regard to what has been and what can be accomplished in the treatment of malleolar fractures. Haenel gives the statistics of -10 cases, treated by different surgeons and under partly unfavorable circumstances; of these, 28 recovered (70 per cent.), while 12 became disabled (30 per cent.); the average loss in earning-efficiency was about 50 per cent. These extremely unfavorable results are hardly what anyone would have expected at the time of this compilation. Incomparably more favorable are the results reported by Jottkowitz from the Knappschaftslazareth at Konigshutte; his patients were under treatment from the first to the last day and under the observation of a physician who supervised the medico-mechanical as well as the purely surgical treatment of the cases. Of 40 cases of malleolar fracture treated under these conditions, 31 (77 per cent.) recovered fully in an average period of 89.4 days, and a few others were able to work at the end of six months. The average period of recovery in cases of fracture of both malleoli was 151.3 days; 742 INJURIES OF THE ANKLE AND FOOT. of 3 cases of this sort, 1 was discharged cured, 1 with 20 to 30 per cent, loss in earning-efficiency, and 1 with 30 to 40 per cent. Of 15 cases of fracture of the lower third of the leg, 4 were discharged cured, 7 with 20 to 30 per cent., and 4 with 30 to 40 per cent, loss in earning-efficiency. The results obtained by Bardenheuer in the Burgerspital in Cologne by extension treatment are almost ideal in this respect; according to Loew's report, all of the patients (68!) with simple malleolar fractures recovered fully, 58 of these within ninety-one days. Of 38 cases of fracture of both malleoli, 37 recovered fully; only 1 remained disabled. Of 5 cases of supramalleolar fracture, all recovered fully within ninety- one days. These results are good evidence of the value of the extension method and especially of the care and experience of the attending surgeon, upon which so much depends. The question of operation is to be considered in exceptional cases in which, in spite of anaesthesia having been used, splinters of the astrag- alus or the tibia or fibula prevent reduction of the astragalus. The question arises whether it is advisable to be satisfied with a partial result, or whether it is not better to remove the splinters. A painful and more or less useless foot can be counted upon in the case of badly reduced splinter fractures, so that active interference is justified. One may expect a useful and movable joint if the interposed fragments can be removed without injuring the malleoli and primary union be secured. The joint can be opened from the inner side and the foot dislocated outward, especially if the fibula is broken; in some instances an external incision will be preferable, and in compound fractures the joint can be approached through the wound. Union with deformity can be but little influenced by means of cor- recting splints; massage and long-continued exercises are beneficial only if the displacement is slight, and furthermore call for great energy and perseverance on the part of the surgeon and patient. If there is considerable displacement, the conditions grow worse from month to month, so that it is useless to prolong conservative treatment. The earlier operation is performed, therefore, the better the results. Eversion of the foot — valgus position — is the most important of the deformities which are left after improper reduction or too early encumbrance of the foot ; it is the result of abduction or eversion fractures, the most frequent of all frac- tures of the malleoli. Pes valgus traumaticus presents a typical picture: the foot is displaced outward and everted, the inner border depressed, the outer elevated; corresponding to the original dislocation, the foot is also frequently displaced backward and extended (equinus position). Above the joint on the outer side there is an angular inflexion of the fibula; the internal malleolus is greatly thickened by callus. In severe cases the body-weight cannot be supported by the foot, and in milder cases only with great pain. The axis of the leg which passes normally through the middle of the sole passes through or to the inner side of the inner border of the foot. When the weight is thrown upon the foot, it is twisted further outward; the resulting laceration of the tarsal liga- ments causes severe pain; deforming inflammation of the joints, effusion FRACTURES OF THE MALLEOLI. 743 in the tendon-sheaths, and atrophy of the muscles of the leg, add to the disturbance. The arch of the foot finally gives way and a static pes planus with all its disagreeable consequences develops from the traumatic pes valgus. The treatment of traumatic pes valgus is by one of three methods: (1 ) forcible correction; (2) osteotomy; or (3) resection. Forcible correc- tion gives good results as long as the callus is soft and yielding — that is in the first six weeks. In v. Bergmann's clinic we have obtained excellent results in this manner, giving up all instrumentation and effecting the correction entirely by manipulation with gradually increasing pressure. If used carefully, the so-called osteoclasts, for example, of Rizzoli, Collin, and others, are supposed to be very serviceable. The advantages of subcutaneous refracture over operation for oblique fractures with malunion need hardly be emphasized; in older cases with firm callus, however, it is dangerous, as the bone is very liable to break at another point. For such cases there still remains the open method of osteotomy and its various modifications. In mild cases transverse division of the fibula will be sufficient; if associated with fracture of the internal malleolus, it will be necessary in addition either to divide the adhesions about the internal malleolus, or more frequently to excise a wedge from the tibia, as the internal malleolus often prevents reduction on account of its dis- placement outward or the excessive callus on the inner side. The operation is as follows: The fibula is exposed through an incision on the outer side of the leg and divided squarely across with the chisel after peeling off the periosteum. If correction is still impossible, the site of fracture on the tibia is exposed through a second longitudinal incision, a wedge is then chiselled out at the site of fracture, not quite through the bone, and the remaining portion fractured. This has the advantage of preserving the periosteum intact on the outer surface of the tibia and of not endangering the soft parts in the interosseous space by chiselling. The size of the wedge must correspond naturally to the amount of deviation. An existing equinus position of the foot is overcome by dividing the tendo Achillis. After correction has been accomplished, the w T ounds are closed with a few sutures, a sterile dressing is applied and the foot is immobilized, somewhat overcorrected, in a plaster-of-Paris splint. Bone sutures are usually unnecessary. We have repeatedly ob- tained excellent results in v. Bergmann's clinic by this method. Oblique osteotomy, which we employ only for marked deviation, has the advan- tage of allowing the fragments to be shifted and lengthened upon each other without being separated, although Trendelenburg has shown that good union results even after simple transverse osteotomy and separa- tion of the surfaces. Helferich chisels partly through the tibia and fibula and then breaks them with Rizzoli 's osteoclast. The method used in France during the decade of 1890 of resecting a large piece of the lower end of the fibula facilitated the correction of the deformity, but made walking impossible without supporting apparatus, so that it has been abandoned. 744 INJURIES OF THE ANKLE AND FOOT. To correct pes varus traumaticus, the traumatic club-foot, which is usually due to improperly reduced adduction fractures, the fibula is divided transversely, or obliquely from above downward and inward, or a small wedge is removed, and if then the foot cannot be mobilized the tibia is divided transversely. In very severe cases, especially those with splintering, even division of both tibia and fibula may not be sufficient; it will then be necessary to enlarge the incision on the inner side down- ward and to open the joint; after previously dividing the fibula it is easy to dislocate the foot outward, remove all interposed fragments from the astragalus or the tibia or fibula and chisel off uneven surfaces; it may be necessary to resect the joint partially. The malleoli should be left if possible to preserve the stability of the joint. Kirmisson reports good results by means of this atypical resection. In v. Bergmann's clinic we have not been compelled thus far to do such extensive operations, and should reserve them for desperate cases. Pseudarthrosis is very rare and is usually the result of great negligence. Its treatment corresponds to that of pseudarthrosis in general. If con- servative methods — a portable plaster-splint, passive congestion, irritation of the fragments — are ineffectual, the fragments should be freshened up and sutured. FRACTURES OF THE TARSUS. Fractures of the Astragalus. — Fractures of the astragalus are com- paratively rare. In 1894 Gaupp collected 60 cases, but it is certain that the injury is more frequent than one would suppose from the literature, for Golebiewski alone saw 77 cases. If the fracture is slight it is difficult to recognize; it has been mistaken for sprain, fracture of the malleoli, and other injuries, and occurring with fracture of the malleoli it has been overlooked. Usually it is produced by falling from a height upon the feet, the bone being crushed between the tibia and calcaneum, less fre- quently it was caused by forced inversion or eversion or direct violence, as in run-over accidents, etc. Most frequently the break is in the least resistant part of the bone, namely, the neck, the fracture-line lying as a rule in the frontal plane. This somewhat typical form is produced by violent flexion of the foot, the front margin of the tibia thus cutting through the neck of the astragalus; a fragment is usually broken off at the same time from the front of the tibia. (Konig.) There may be little or no displacement of the fragments; in a number of cases the body of the astragalus was displaced backward and wedged fast between the tibia and fibula and the tendo Achillis. (Fig. 468.) These cases have been classed improperly with dislocations of the astragalus. Fracture of the body of the astragalus is more rare. The bone may be broken into three fragments: an anterior, composed of the neck and head; a middle, of the trochlea; and a posterior, of the posterior process: or it may be divided horizontally into an upper and lower fragment: or obliquely or sagittally into two lateral fragments. A longi- tudinal and transverse fracture may be combined to form a T-fracture. FRACTURES OF THE TARSUS. 745 The bone may be crushed or comminuted. Avulsion or loosening of superficial portions of cartilage or bone, such as occasionally happens as a complication of dislocation of the astragalus, are of slight signifi- cance. In a relatively large percentage of cases fracture of the astragalus is complicated by wounds of the soft parts produced by displaced frag- ments or by simultaneous fractures of the malleoli. Diagnosis. — The diagnosis of fracture of the astragalus may be diffi- cult in the absence of any displacement; the symptoms are then those of a severe sprain, the real condition sometimes being detected only after the swelling has subsided by the presence of callus and persistent limita- tion of motion in the ankle-joint. In simple sprain the swelling and extravasation of blood are usually not so marked; in fracture of the astragalus the tenderness on pressure is limited chiefly to the astragalus, and the attempt to bear the weight on the foot is extremely painful. The Fig. 468. T ! Fracture of the astragalus. (Kohlhardt.) intense pain also produced by flexing the foot is characteristic; crepitus may be elicited at the same time. In spite of careful inspection and palpation the diagnosis is not always possible; in doubtful cases the examination should be continued under anaesthesia and with the a>ray. Even in these cases the .r-ray can be deceptive, so that it is advisable always to obtain skiagraphs of the sound foot also, if possible, for comparison. If displacement exists, the diagnosis is easier; fragments may some- times be felt beneath the stretched skin at abnormal points and their contour recognized in front of or behind the malleoli. In fracture of the neck the foot is usually extended and everted, in the other forms of fracture it is generally flattened or in the valgus position, and the malleoli are lower than usual. Fracture of the posterior process, in the groove of which runs the tendon of the flexor hallucis longus, occurs alone or in connection with other fractures, and is denoted by thickening 746 INJURIES OF THE ANKLE AND FOOT. and tenderness behind the internal malleolus and limitation of the movements of the great toe. (Golebiewski.) Treatment. — In the absence of displacement the foot can be immobilized at a right angle to the leg for three or four weeks; later, massage and passive movements, and at the end of several more weeks the full weight can be placed on the foot. If the fragments are displaced, they should be reduced by traction and pressure if possible. Otherwise operation has to be considered; it has been performed successfully among others by Sick. If the fragments cannot be coaptated properly, one or more of them, or even the entire astragalus, may have to be removed to restore the mobility of the joint, v. Brims was compelled in one case to remove the astragalus five weeks after injury; the bone was extracted through an outer incision in front of the fibula; the result was ideal; two and one-half years later there was no difference in the gait in the two feet. In com- pound fractures, if suppuration occurs, the entire bone should be removed. Fracture of the astragalus, especially with any great amount of dis- placement, is always a serious injury. In many cases the restoration of function is complete, but in others the mobility of the foot is perma- nently impaired; even complete ankylosis may develop in the ankle-joint, and the lasting disturbance may necessitate extirpation of the thickened bone or resection of the joint months after the injury, as shown by v. Brims' case. The earning-efficiency is impaired from 15 to 20 per cent, or more, an average of 30 per cent. Fracture of the Calcaneum.— Fractures of the os calcis are more typical than those of the astragalus. Although until recently regarded as a rare injury, the literature of fracture of the calcaneum has been considerably increased since the enactment of accident legislation (Ger- many). According to Ehret, fractures of the os calcis constitute 2 per cent., and according to Golebiewski 4 per cent, of all accident cases. Compared with our own experience these figures are high. An accurate knowledge of fractures of the calcaneum is indispensable on account of the severe results which follow non-recognition or improper treatment of the injury. Fractures of the tuberosity have been known for the longest time. They are usually tear fractures produced by violent con- traction of the muscles of the calf. It is generally the entire portion of bone lying behind the calcaneo-astragaloid articulation which is torn off, exceptionally the point of attachment of the tendo Achillis. (Plate XX.) As properly emphasized by Gussenbauer, the fracture is not a pure tear-fracture, but is the result of two component forces, the trac- tion of the extensors and the pressure or blow due to the weight of the body in falling. The fracture is commonly the result of falling upon the extended foot. The fragment is drawn upward only slightly by the tendo Achillis, as it is held by the plantar fascia and the plantar muscles arising from the calcaneum. The symptoms are clear: inability to stand or to walk; false motion and displacement of the tuberosity, and crepitus obtained on drawing down the fragment. The splint should be put on with the knee flexed and foot extended to the utmost and with adhesive-plaster strips applied over the fragment to FRACTURES OF THE TARSUS. 747 bind it down in place. If the fragment cannot be properly reduced, the functional disturbance is usually permanent; the patient complains of pain in the sole of the foot, the extensor muscles atrophy and hard work is impossible. It is therefore advisable, if the fragment cannot be held in place with a splint, to nail it in place through the skin, as recom- mended by Gussenbauer. If greatly displaced, it should be exposed and sutured in position. The occurrence of pure tear-fractures of the posterior process cannot be questioned. As seen with the .r-ray, they are characterized by the absence of all symptoms of compression (thicken- ing in the spongiosa, irregular, indistinct outline); the line of fracture is vertical. There is another type of tear-fracture in which a thin plate of bone is torn from the upper surface of the posterior process by the tendo Achillis, the line of fracture being horizontal, parallel to the lamellar structure. (Helbing.) (Fig. 469.) If the fragment is much displaced, it should be sutured. (Borchardt.) Fig. 469. Avulsion fracture of a horizontal plate. Fractures of the sustentaculum tali, of the inconstant processus infra- malleolaris, and of the tuber calcis, the point of origin of the short muscles of the sole, are rare, of less importance, and are usually associated with other fractures of the calcaneum. Isolated fracture of the sustentaculum tali, which naturally produces a valgus position of the foot, was first re- corded by Abel. It may entail functional impairment of the flexor com- munis digitorum and of the flexor hallucis. Ehret saw a case of avulsion of the tuber calcis, thus confirming Golebiewski's belief of its occurrence; a movable fragment is felt in place of the tuberosity. Bidder was the first to observe a tear-fracture of the processus inframalleolaris; he referred it to the tension of the strong calcaneofibular ligament. Whether this explanation is correct or not, is still an open question. Golebiewski is inclined to regard the fracture as due to direct violence; at least it was so in his own case. At the end of two years the foot was still consid- erably disabled and a distinct mass of callus could be felt about the peroneal tendons. 748 INJURIES OF THE ANKLE AND FOOT. The fractures by compression (par ecrasement) are by far the most important of the fractures of the calcaneum. They are produced usually by falling upon the feet, exceptionally by direct violence applied to the heel. In the former case the more solid astragalus is forced through the softer calcaneum like a wedge. (Ballenghien.) These compression fractures are usually made up of transverse fractures, the greater part of which generally pass through the sinus tarsi, and of longitudinal frac- ture \s running more or less horizontally near the lower surface; there is also some irregular splintering. (Fig. 470.) The severity of the frac- ture depends upon the distance of the fall and the weight of the patient; if both components are slight, the fracture and the displacement may be insignificant or absent; if the force is very great, the bone may be literally crushed, in which case there are also usually fractures of the Fig. 470. Comminuted fracture of the calcaneum. (Anger.) malleoli or astragalus. The part of the calcaneum chiefly affected by the fracture depends upon the position of the foot at the time of injury. If the foot strikes the ground while inverted, it is the inner border, sus- tentaculum and neck, which are affected chiefly; if the foot is everted, the outer margin of the bone is injured; if the foot is flexed, it is mainly the posterior part, and if extended, it is the anterior part which suffers. Diagnosis. — The difficulty of diagnosing recent fractures of the cal- caneum is shown by Ehret's statistics of 47 cases, in only 3 of which was a correct diagnosis made immediately after the injury, the others being regarded as fractures of the malleoli or sprains. The reports of Baehr, Korte, Golebiewski, Thiem, Sliwinski, Helferich and others, are similar. Fissures and fractures without displacement may not be detected on inspection and palpation; the symptoms may be so slight aside from FRACTURES OF THE TARSUS. 749 the effusion that the fracture is overlooked; sometimes the weight can be placed on the calcaneum; if the fragments are displaced, the heel is broader; the localized tenderness is characteristic and crepitus may be felt at the same time; movement of the ankle-joint is fairly free, but is very painful if forced. The foot is usually in the valgus position and appears flattened; the malleoli are nearer the sole of the foot; in a few cases the foot was in the varus position. In every case of injury due to falling from any considerable height, even if other lesions are present, the calcaneum and astragalus should be examined for fracture. Finally an examination under anaesthesia and with the x-ray if necessary will aid the diagnosis. Course. — The subsequent course of fractures of the calcaneum is rather peculiar and characteristic. In the mild cases without deformity and with only slight subjective symptoms which were regarded and treated as sprains, the first attempts to walk at about the end of the Fig. 471. Fracture of the anterior process of the calcaneum from an z-ray. (v. Bergmann's clinic.) second week caused considerable pain on account of the irritation of the callus. This unusual pain should always incite one to make a careful investigation, and the case should alwavs be treated as a fracture if doubt exists. The long duration of recovery is almost pathognomonic, especially in cases with displacement; complete recovery has thus far been an exception. In Ehret's 47 cases there were only 5 complete recoveries; in the others considerable functional disturbance persisted, the pain in the sole of the foot and in the calf when walking compromising the earning-efficiency of the patient for years or even permanently. As long as a cane is necessary in getting about an indemnity on a 50 to 60 per cent, basis is not too high. (See Accident and Judgment.) Aside from the long-continued subjective discomfort, the gait is not infrequently characteristic; the patient avoids placing any weight upon the heel, and therefore walks more on the outer or on the inner border of the foot, according to the site of fracture. There is also an evident broadening of the heel, shown clearly by charcoal impressions of the 750 INJURIES OF THE ANKLE AND FOOT. feet, which is referable to callus production in the crushed bone; the broadening not infrequently corresponds to a decrease in the vertical diameter and as a result to a lowering of the malleoli. The grooves at the sides of the tendo Achillis are often obliterated. (Fig. 472.) As it is usually the outer part of the bone which is crushed the most, the thickening under the external malleolus is more pronounced. This thickening, as emphasized properly by Thiem, is often mistaken for the callus of fractures of the malleoli. A flat-foot usually develops with some inversion ; if the patient walks on the outer border of the foot, an actual club-foot can develop. Pes valgus does not occur apparently unless the external malleolus is fractured. Motion is free in the ankle- joint, but lastingly impaired in the calcaneo-astragaloid and calcaneo- cuboid joints — that is, eversion and inversion. Fig. 472. Old fracture of the calcaneum. Left normal foot. Right foot with fracture of the calcaneum; note broadening of heel and obliteration of the hollows at both sides of the tendo Achillis. Treatment. — Compression fractures without displacement only require that the limb be immobilized in a T- or plaster-splint; those with displace- ment demand that the fragments be replaced under anaesthesia and a plaster-splint applied. Union takes place very slowly, as stated, so that walking should not be allowed too early, not before the ninth week; later a long course of baths, massage, and passive motion is likely to be necessary. Fractures of the Small Tarsal Bones. — The small bones of the tarsus are rarely fractured save by severe direct violence, so that as a rule the fractures are comminuted and compound and associated with DISLOCATIONS OF THE FOOT. 751 extensive laceration and contusion of the soft parts. 'Flic significance of the injury therefore depends upon threatened infection. Fracture by indirect violence is very rare, and in the absence of displacement is recognizable only by eliciting crepitus, or with the zc-ray. Treatment.— The foot should he immobilized for three or four weeks. Recovery usually takes place without any functional disturbance. Fracture of the scaphoid by indirect violence has recently been reported by Kohlhardt. DISLOCATIONS OF THE FOOT. By dislocation of the foot is understood displacement of the foot in the tibiotarsal joint, the relation of the astragalus to the malleoli being changed, that of the malleoli to each other unchanged. The dislocation may be lateral, or forward, or backward. In addition to these two main types, namely, lateral and sagittal, one speaks of an upward disloca- tion when the astragalus is forced up between the tibia and fibula. According to the modern generally accepted view of dislocation, the distal bone is the one dislocated, in this case the astragalus; so the older classifications of Malgaigne and Cooper, which spoke of dislocation of the tibia, no longer apply. The direction of the dislocation is determined by the relation of the dislocated, therefore distal, bone to the proximal bone, so that there is no question as to what is meant by forward or back- ward dislocation of the foot. It is different with lateral dislocations: some authors (Konig, Bardeleben) designate a fibular displacement of the foot as inward dislocation of the foot because the trochlea of the astragalus is turned toward the internal malleolus. Others (Lossen, Hoffa, Fischer, Wendel) designate a fibular displacement of the foot as an outward dislocation, which is more in accord with the natural rela- tions. Although the principle of the Bardeleben-Konig designation is the more correct one, still it seems less involved to us to name the dislo- cation from the position of the foot as a unit recognizable from without, rather than from the position of the astragalus, which cannot always be determined readily by palpation. Furthermore, Lossen emphasizes the fact that the position of the astragalus is not constant, that in addition to being rotated on its sagittal axis, it is displaced in the direction in which the foot is dislocated ; so it may be present at the outer side of the fibula in outward dislocation, hence it would be necessary to have different terms for one and the same dislocation of the foot according to the position of the astragalus. Taking the foot as a unit, we therefore designate (with Lossen, Hoffa, G. Fischer, Stetter, Wendel) fibular displacement of the foot as dislocation outward, and tibial displacement as dislocation inward. All dislocations of the foot are liable to be complicated by fractures, especially of the malleoli; this applies particu- larly to lateral dislocations, which in the greater majority of cases occur secondarily, namely, after the malleolus has been broken off. The latter dislocations have therefore been designated after the example of Stro- meyer as dislocation fractures or fracture dislocations. (Fischer.) In 752 INJURIES OF THE ANKLE AND FOOT. spite of the frequency of this combination of dislocation with malleolar fracture, Wendel has recently collected 10S cases of uncomplicated dislocations of the foot. Lateral Dislocations of the Foot. 1 Outward Dislocations. — Outward dislocations are produced by violent rotation of the foot outward about a sagittal axis — that is, eversion (eversion dislocation); or by rotation about a vertical axis, namely, outward rotation of the tip of the foot (rotation or abduction disloca- tion). The astragalus being so firmly mortised in the fork of the malleoli always causes the malleoli to be broken in eversion dislocation, and generally in the form of the typical eversion fracture (Pott's fracture). Symptoms. — The symptoms of the usual form of outward dislocation are the same as those of eversion fracture, except that the foot is even more everted, so that the dorsum faces inward, the sole outward (Fig. 473); the outer border of the foot faces upward, the inner downward. Fig. 473 Outward dislocation of the foot. (Anger.) The astragalus may lie beneath the internal malleolus, or obliquely between the separated malleoli; or it may be displaced so far outward that it lies under the external malleolus or at the outer side of the fibula. The internal malleolus may perforate the soft parts at the inner side of the joint. An uncomplicated outward dislocation should be without symptoms of fracture; but this happens so rarely that many surgeons question its occurrence. This view is incorrect, however, as Wendel found 19 uncomplicated outward dislocations among 10S cases. The so-called rotation dislocations (G. Fischer) or, better, abduction dislocations are frequently accompanied by abduction fractures. According to Henke, the mechanism is as follows: As the foot is twisted outward the inner lateral surface of the astragalus is drawn away from 1 Spath divided lateral dislocations into outward and inward dislocation-by-rotation; to be more accurate, he added the terms horizontal and vertical according as the foot was rotated about a horizontal or vertical axis. The author's dislocation by eversion (pronation) is therefore equivalent to Spiith's dislocation outward by horizontal rotation. DISLOCATIONS OF THE FOOT. 753 the articular surface of the internal malleolus. If the force continues, the malleolus slips behind the posterior part of the trochlea and the outer margin of the trochlea presses the fibula backward. As a rule the fibula breaks just above the malleolus. In the living subject the foot is usually fixed while the body rotates toward the other side. The case combined with fracture of the fibula recently seen in the Berlin surgical clinic resembles the cases of Fischer and others and is charac- teristic. (Fig. 474.) Wickhoff gives a very plausible explanation for Fig. 474. Abduction dislocation of right foot with fracture of fibula, (v. Bergmann.) the rare cases of dislocation without fracture of the fibula; his idea is that the fibula may not break if there is sufficient rotary mobility in the upper tibiofibular joint, and the fibula is flexible enough to be twisted to the given angle of abduction. Wendel collected 8 cases of uncom- plicated abduction dislocation from the literature. The most prominent symptom is the abduction of the foot through 90 degrees, so that it points directly outward, the inner border facing forward, the outer backward; at the same time it is slightly extended. The astragalus is wedged between the malleoli, which are separated; the tibia projects forward beneath the skin; the fibula can be felt behind. Vol. III.— 48 754 IX JURIES OF THE ANKLE AND FOOT. If there is a simultaneous abduction fracture the wedging of the astraga- lus between the malleoli is less firm; the point of fracture is easily found above the malleolus on the fibula; as a result of the fracture the foot is slightly everted. Treatment. — The reduction of eversion and abduction dislocations is best effected by extending the foot and flexing the knee to relax the tendo Achillis, and then making downward traction upon the foot and adducting or inverting for both) with direct pressure upon the tibia and fibula. Inward Dislocations. — Inward dislocations are best divided into two groups, namely, those by inversion or supination, and those by adduction or inward rotation of the tip of the foot. Fig. 475. *-***-- Dislocation of the foot by inversion, (v. Brans.) Dislocation by inversion is produced by violent rotation of the foot about a sagittal axis, the same force usually producing an inversion fracture without much displacement. As great violence is required to dislocate the foot, the injury is often combined with multiple fractures of the astragalus, calcaneum, tibia, and fibula, and with wounds of the joint. Whereas dislocation inward combined with fracture is rather less frequent than the corresponding dislocation outward, uncomplicated inward dislocations are much more frequent than the corresponding outward variety. As emphasized by "YYendel, this may be due in part to the shortness of the internal malleolus, which is less exposed to pressure in inversion of the foot, but it is due more to the greater strength of the malleolus; the greater power of resistance of the internal malleolus was noticed by Honigschmied, who could produce fracture of the internal malleolus in only one instance by violent inversion in 18 experi- DISLOCATIONS OF THE FOOT. 755 ments on the cadaver. There are only 36 uncomplicated dislocations by inversion known in literature. Symptoms. — The symptoms are as follows (Fin;. 47o): The loot is inverted as in club-foot, the inner border is elevated, the sole faces inward. The foot may he rotated !)() degrees on its long axis; the trochlea of the astragalus faces outward and lies beneath the external malleolus. Wounds of the joint are common, and are chiefly due to the fibula perforating outward. Dislocation by adduction, produced by violent inward rotation of the foot about its vertical axis is extremely rare; Wendel collected 3 cases. The foot points inward, the outer border facing forward, the inner backward; the astragalus may lie behind the tibia and fibula under the internal malleolus, or at the inner side of the tibia. Treatment. — The reduction of inward dislocation is easy as a rule by flexing the knee, making traction on the foot, and increasing the patho- logical position, then everting or abducting (or both) with direct pressure upon the tibia and fibula. Sagittal Dislocations of the Foot. Backward Dislocations. — According to Henke and Honigschmied's experiments, backward dislocations can be produced by forced extension of the foot. In the living subject it occurs in the same manner by falling backward with the foot fixed or by falling upon a surface which inclines forward. The posterior articular margin of the tibia forms a fulcrum against the trochlea, by the action of which the capsule is torn in front, and the force continuing drives the tibia forward over the trochlea and through the tear in the capsule. The tibia then becomes fixed if the foot is flexed again to a right angle. Extensive laceration of the capsule and ligaments is essential for the production of the dislocation. The dislocation may be complete or incomplete. In the majority of cases the fibula is broken, the upper fragment being displaced forward with the tibia, the lower backward with the astragalus. Occasionally the internal malleolus is torn off. The skin is frequently perforated. Figs. 476 and 477 are from a case produced by a fall in the typical manner with the foot extended. The foot was firmly fixed in the pathological position; a fracture of the fibula, which was not palpable, was shown by the a>ray taken laterally but not sagittally. This shows the neces- sity of making two exposures and also the possibility that the number of WendePs uncomplicated dislocations would have been decreased by examination with the a*-ray. Symptoms. — The symptoms are very characteristic; the front of the foot is shortened and the heel correspondingly lengthened; the tibia projects on the dorsum of the foot, the sharp edge of its articular surface being felt beneath the tense skin. In a thin foot one can sometimes see that the extensor tendons are more tense and prominent than usual on the dorsum. Behind, the tendo Achillis curves downward and back- ward to the tuberosity of the caleaneum and there is a deep furrow in 756 INJURIES OF THE ANKLE AND FOOT. front of it on either side. The foot is usually fixed; in a few cases it can be extended or flexed slightly. Treatment. — Reduction is by forced extension, then forward traction on the foot with counterpressure on the leg, and then flexion. Forward Dislocations. — Uncomplicated dislocation forward is less common than the corresponding backward variety; according to Wendel, Fig. 476. Backward dislocation of the foot. (v. Bergmann.) Fig. 477. A'-ray of Fig. 476. 11 to 26. The dislocation is produced by forced flexion of the foot. The front articular margin of the tibia impinges against the depression on the astragalus in front of the trochlea; the capsule is thus torn open behind, and if the force then drives the foot forward or the leg back- ward, the trochlea is pushed forward on the tibia and fibula, the tibia becoming fixed in the depression behind the trochlea as soon as the foot is extended to a right angle. The dislocation may be complete or incomplete. Disi.iKATlnss OF THE FOOT. 757 Symptoms. — The fool appears to be lengthened (Fig. 478); the heel is less prominent; the tendo Achillis runs directly downward; the malleoli arc depressed; the trochlea can be fell in front. The foot is sometimes everted or inverted and may be slightly flexed or extended. Diagnosis. — As in posterior dislocation, the diagnosis is usually simple, except where the dislocation is incomplete or there is mueh swelling; in either ease it may be mistaken for malleolar or supramalleolar frac- ture. Treatment. — Reduction is by extreme flexion and backward pressure on the foot with counterpressure, followed by extension. Fig. 478. Forward dislocation of the foot. (Anger.) Upward Dislocations. — Only 5 uncomplicated cases of this sort have been published, aside from a few associated with fracture of the tibia or fibula. The dislocation is produced by falling upon the foot or upon the heel; the foot is thus driven upward between the tibia and fibula; the foot appears shortened because the astragalus is wedged between the tibia and fibula; the malleoli are depressed. Treatment. — Reduction is apparently easy by making traction on the foot. Perforation of the skin is not an uncommon occurrence, as stated, in all dislocations of the foot. One or both malleoli may perforate at the time of injury or later, following necrosis of the skin due to pressure of the bones. If the perforation is recent, the dislocation is reduced after carefully preparing the limb and inserting drains of iodoform gauze in the wound. If reduction is difficult, the wound should be enlarged; 758 INJURIES OF THE ANKLE AXD FOOT. if still impossible, part of the projecting bone is excised; the latter applies also if the bone is soiled. If suppuration occurs, resection — usually only partial — is necessary. It generally gives good functional results ami makes amputation unnecessary as a rule. The after-treatment of dislocations of the foot demands great care; even the dislocations unaccompanied by fracture require immobilization for from four to six weeks on account of the extensive laceration of the ligaments. Fractures require their appropriate treatment. Old dislocations usually interfere greatly with locomotion. This applies especially to the backward variety, after which the foot remains in the equinus position. The talipes calcaneus position, which is apt to develop after non-reduction of a forward dislocation, is somewhat less disabling. Old dislocations can apparently be reduced after some length of time; Hiiter reduced a forward dislocation at the end of six months. If reduction is impossible even after dividing the tendo Achillis, operation, with division of the angularly united fracture or resection of the joint, is indicated. DISLOCATION OF THE TARSAL BONES. Of the dislocations of the astragalus, we distinguish subastragaloid dislocation, the ankle-joint being intact, and total dislocation, in which the bone is torn from all its attachments, as described by Broca in 1S53. Previous to this date the dislocations of the astragalus in the tibiotarsal and mediotarsal joints had all been classified together as dislocations of the astragalus. Subastragaloid Dislocation. — This form is very rare, being produced only by great violence acting more or less directly upon the mediotarsal joint and tearing the strong ligaments in the sinus tarsi. We owe our knowledge of the mechanism to Broca and Henke. The foot, the dislocated part, may be displaced inward, outward, backward, or forward, the two former varieties being most frequent, the latter, the forward variety, being very rare. Dislocation Inward. — By forced inversion and adduction of the foot, as in falling upon the outer edge of the foot, the posterior border of the sustentaculum becomes a fulcrum, the astragalus and calcaneum are forced apart at the outer side, the head of the astragalus becomes disar- ticulated from the scaphoid, the interosseous ligament between them is torn, and the astragalus is pushed forward by the weight of the leg over the calcaneum; it may impinge against the front of the latter or even slip beyond it outward over the articular facet. (Lossen, Henke.) The foot is adducted and inverted as in talipes varus (Figs. 479 and 480); the inner border appears concave and shortened, the outer convex and lengthened. The external malleolus is more prominent and the cal- caneum is absent below it; in front, the head of the astragalus can be seen and felt lying upon the front of the calcaneum or upon the cuboid. The prominence of the internal malleolus is effaced; below it can be lUsLOCATloy OF THE TARSAL BONES. 759 distinctly fell the inner border of the calcaneum and the sustentaculum. Further in front one can feel the scaphoid projecting abnormally. Active motion is lost, passively the fool ran be flexed, extended, and inverted in the tibiotarsal joint, l>nt not everted, the latter being pathognomonic in case the swelling prevents palpation. Fig. -17«J. Kir.. -ISO. Subastragaloid dislocation inward. (Anger.) Subastragaloid dislocation inward. (Hoffa.") Dislocation Outward. — This is produced by forced eversion, as in falling heavily with the foot turned outward or by a blow against the outer side of the leg while the foot is fixed. The fulcrum is the upper anterior surface of the calcaneum; the joint between the astragalus and calcaneum gapes at the inner side, the interosseous ligament between the two bones is torn, and the astragalus slips inward over the articular facets of the calcaneum and over the scaphoid while the foot is everted. The pos- terior facet of the astragalus lies upon the sustentaculum and the head lies above and to the inner side of the scaphoid; if the force continues, the astragalus and calcaneum may become so separated that the foot lies entirely to the outer side of the external malleolus. The position of the foot is like that of a high-grade pes planus. (Figs. 481 and 482.) The calcaneum and cuboid project abnormally at the outer border of the foot, and above them there is a depression at the site of the external malleolus and head of the astragalus. The internal malleolus is less prominent than usual; in front of it the head 760 INJURIES OF THE ANKLE AND FOOT. of the astragalus projects excessively beneath the skin. Below and in front of the latter on the dorsum can be felt the scaphoid, behind which the soft parts can be indented slightly. Flexion and extension are possible in the tibiotarsal joint, but eversion, and especially inversion, are limited. The external malleolus is commonly broken off by the pressure of the calcaneum. Fig. 482. Subastragaloid dislocation outward. (Anger.) Subastragaloid dislocation outward. (Hoffa.> Dislocations Backward and Forward. — The very rare sagittal disloca- tions of the astragalus are produced by forced extension or flexion; by extension the astragalus is levered off against the posterior surface of the facets of the calcaneum, and by flexion against the anterior surface of the same; it is pressed forward by the tibia over the scaphoid, or backward upon the posterior part of the calcaneum. So the backward variety of subastragaloid dislocation is produced by hyperextension (Fig. 483) and the forward variety by hyperflexion (Fig. 484). Only a few cases have been reported of these two forms. Hildebrand distinguishes two types of backward dislocation, in one the head of the astragalus points forward, in the other downward with its articular surface resting upon the upper surface of the scaphoid and cuboid, so that its long axis represents a prolongation of the axis of the tibia. In the second type the head of the astragalus is missing on the dorsum, the distance between the scaphoid and cuboid is greater,. DISLOCATION OF THE TARSAL BONES. 761 and aversion and inversion of the foot arc freer than in the first type. Quenu reports a ease in which on section the head of the astragalus lay upon the calcaneocuboid joint. This was a transition form between backward and inward dislocation; the foot was fixed in the varus position; the length of the heel was increased; motion in the ankle-joint normal. Quenu classifies backward, inward, and backward and inward disloca- tions as variations of the same dislocation, which he terms dorsal dislo- cation, the common characteristic of which is the position of the head of the astragalus upon the dorsum to the outer side of the tendon of the tibialis anticus. He accordingly divides subastragaloid dislocations into dorsal, outward, and forward dislocation, a classification commonly used in France. Burnett and Kaufmann report a case each in which the scaphoid, astragalus, and malleoli were in their normal relation, Fig. 483. Fig. 484. Subastragaloid dislocation backward. (Hoffa.) Subastragaloid dislocation forward. (Hoffa). while the rest of the foot was dislocated backward and inward in Bur- nett's case, and backward and outward in Kaufmann's. (Fig. 485.) In forward and backward subastragaloid dislocations the foot is apparently lengthened or shortened similarly as in tibiotarsal dislo- cations, but differs from the latter in that flexion and extension are preserved in the tibiotarsal joint. Formerly reduction was frequently unsuccessful, chiefly because the mechanism was not known. But even to-day it can be prevented by interposition of capsule, ligaments, muscles, or fragments of bone. The lateral dislocations are reduced best by flexing the knee fully, increasing the pathological position, extending the foot strongly, and then carrying it over into the opposite position. The sagittal dislocations are reduced in the same manner with the knee flexed and the foot extended or flexed as demanded, and if necessary by direct pressure upon the astragalus or also upon the scaphoid. If 762 INJURIES OF THE ANKLE AND FOOT. reduction is impossible or was previously neglected, operation is indi- cated, and if still unsuccessful, the head or the entire astragalus should be removed. Total Dislocation of the Astragalus. — Total dislocation — the double dislocation of the astragalus of Boyer and Malgaigne — is a combination of tibiotarsal and mediotarsal dislocation of the astragalus, and exists if the astragalus is torn from all its articular connections. This very rare injury is more frequent than subastragaloid dislocation, yet only 50 cases are known, and Kronlein did not see a single instance among 400 dislocations. Four types are distinguishable practically: forward, backward, outward, and inward. In addition to these, many variations and combinations, especially of lateral and sagittal dislocations, occur, also complete reversal of the astragalus about its vertical or long (horizontal I axis. Complete reversal is seen chiefly in connection with other dislocations. Fig. 485. Subscaphoid dislocation. (Kaufmann.) The mechanism is very complicated, and in spite of long study sur- geons are agreed only on the fact that lateral dislocations are produced essentially by great violence acting upon an everted or inverted foot. Rognetta assumed from experiments that forward dislocation was pro- duced by forced extension of the foot while the leg was pressed backward. Experimentally Dauve produced forward and outward dislocation by extension and inversion, and forward and inward dislocation by exten- sion and eversion. Henke demonstrated just the opposite. After dividing all the ligaments, or after dislocating the astragalus in the tibiotarsal and then in the mediotarsal joint, and reducing these dislo- cations, if the foot were flexed, a forcible jerk of the tibia produced forward dislocation of the astragalus, and backward dislocation if the foot were extended. Therefore Henke assumed that anterior disloca- tion of the astragalus was produced by hyperflexion and simultaneous eversion or inversion, and posterior dislocation by hyperextension with inversion or eversion. Both theories have their defendants: Phillips and others side with Rognetta and Dauve, Lossen with Henke, and cases substantiating both theories have been seen. DISLOCATION OF THE TARSAL BONES. 763 Stetter claimed that forward dislocation could be produced by either forced flexion or extension, the essential being previous excessive eversion or inversion. This was supported by the findings of various operations for dislocation of the astragalus. (Loebker.) Riedinger and Middel- dorpf describe specimens of forward and outward dislocation in which, in addition to a fracture on the inner side of the astragalus evidently due to forced eversion, there was a wedge-shaped fracture with apex forward of the back of the trochlea, evidently due to forced extension. Two similar cases were reported by Middeldorpf. Schlatter demon- strated that with the foot slightly extended severe lateral violence alone could produce anterior dislocation. That the rare backward dislocation Fig. 486. Fig. 487. Forward and outward dislocations of the astragalus. (Anger.) Inward dislocation of the astragalus. (Anger.) is evidently produced by forced extension of the everted or inverted foot is corroborated by the experiments of Heinecke and Dorsch made in L889. Diagnosis. — The diagnosis of total dislocations of the astragalus is usually easy except in the presence of much swelling, when anaesthesia will be required. In inward dislocation the foot is everted, abducted, and slightly extended. (Fig. 4S7.) [?] In outward dislocation the foot is adducted and inverted; it may be inverted so that the sole faces directly inward; the astragalus projects prominently beneath the skin on the dorsum, to the inner or outer side of the middle line, according as the dislocation is forward and inward or forward and outward; the bone may perforate the skin. In forward dislocation the foot is extended 764 INJURIES OF THE ANKLE AND FOOT. and the malleoli are nearer the ground ; the foot is apparently lengthened and the astragalus can be felt beneath the skin in front. In backward dislocation the foot appears shortened; the astragalus is felt behind between the tibia and tendo Achillis, nearer either the outer or inner malleolus. In front a depression replaces the normal resistance of the astragalus. Total reversal of the astragalus about its horizontal or vertical axis is very difficult to recognize. In Seiler's case of rotation about the long axis the foot was displaced outward, the toes were flexed; active and passive motion in the tibiotarsal joint was impossible. On the inner side of the foot below the malleolus, the head, posterior part of the body, and between them the convex lower articular surface of the astragalus could be distinguished. (Fig. 488.) On operation a fracture of the internal malleolus and of the sustentaculum were also found. Fig. 488. Internal malleolus. Posterior portion of body of astragalus. Total dislocation of the astragalus with rotation about its long axis. (Seller.") These total reversals of the astragalus are only explained by a rotating force acting on the dislocated bone; whether it is transmitted from the tibia or due to muscular action, or whether the rotation is caused by the action of two opposing forces, is still unknown. The condition has not been produced experimentally. The dislocation is frequently com- plicated by perforation of the skin by the head of the astragalus. In some instances there was also a fracture of the astragalus, fragments of the bone being torn off by the ligaments, or the posterior part of the bone was compressed, or the head was separated from the body at the neck. Treatment. — Reduction is best accomplished, with the knee and hip flexed to relax the muscles, by making downward traction on the foot while the pathological position is increased, and then by direct pressure on the astragalus. Dislocations complicated by wounds of the soft parts should be treated on general principles; the wound should be drained with strips of iodoform gauze. According to the available DISLOCATION OF THE TARSAL BONES. 705 statistics, reduction has been successful in only one-fourth of the cases. If the dislocation remains unreduced the function is usually bad, the skin is apt to undergo pressure necrosis, the astragalus becomes necrotic, and suppuration with all its serious consequences follows. Excision of the astragalus has therefore been recommended, especially by Xelaton, and employed by most surgeons. Since the introduction of antisepsis, Hamilton (1884) has reported 11 cases in which operation and reduction were successful, but in 3 of these the astragalus had to be removed later. Operative reduction should always be attempted unless the asepsis of the wound is questionable; the wound should be enlarged appropriately and drained with iodoform gauze. Soiled splinters of bone are excised. If suppuration occurs, the astragalus is removed; even then the function is fairly good, as the malleoli fit over the calcaneum and the foot is fairly movable with only a slight tendency to an equinus position, v. Bergmann's success in operating in 1892 for simple non-reducible dis- locations has led him to recommend operation for all cases not reducible under anaesthesia. The suggestion has been followed since then by several surgeons. As the callus, in the case of fractures, was found to impair the function of the ankle-joint, the fragment has been extracted, but the advantage of such partial resection over complete removal of the bone has not been definitely settled. Dislocation of the Calcaneum. — Lossen reports a few cases of out- ward dislocation of the calcaneum. In Dumas' 2 cases the outer and upper surface of the calcaneum was felt below the external malleolus, which was deep in the soft parts; the front of the calcaneum formed a distinct prominence above the cuboid. The astragalus was in its normal relation to the scaphoid and tibia; below it the normal resistance of the calcaneum was absent. Reduction was by inward pressure upon the cal- caneum and counterpressure upon the leg. Dislocation in the Mediotarsal or Chopart's Joint. — Although dis- puted by many surgeons, especially on the authority of Broca and Henke, the occurrence of dislocation in Cho- part's joint cannot be doubted at the present time. It has been demon- strated in 2 cases of Thomas and Anger. In these the head of the astra- galus and the anterior articular surface of the calcaneum projected dis- tinctly beneath the skin above the second row of tarsals. Fuhr's recent investigations corroborate the observations of Petit, Bell, Cooper, and Smith. In 1 of Fuhr's 2 cases there was complete inward dislocation. Fig. 489. Inward dislocation of the foot in Chopart's joint. (Fuhr.) 766 IX JURIES OF THE ANKLE AXD FOOT. (Fig. 489.) The patient, twenty years old, had been run over by a loco- mobile. The left foot was adducted and inverted and sharply concave in front of the inner malleolus. The head of the astragalus and the an- terior articular surface of the calcaneum could be easily recognized under the tense skin in front of the outer malleolus. Under anaesthesia the scaphoid, concealed by extravasation, could be felt in front of the inner malleolus. Reduction was easy by traction on the foot and direct pressure. In the other case the dislocation was outward, and resulted from fall- ing backward off a stepladder, the left foot being caught between the two lower rungs while the body fell to the left. The foot was slightly everted and abducted and broadened in front of the malleoli; the head of the astragalus was felt under the tense skin close in front of the inner malleolus; on the outer side of the foot could be felt the articular surface of the calcaneum for the cuboid; the relation of the calcaneum to the malleoli was normal. Reduction was by forced abduction in Chopart's joint with the calcaneum fixed and with pressure upon the astragalus. The dislocations in Chopart's joint are very similar to subastragaloid dislocations except that the normal relation of the astragalus to the cal- caneum is unchanged. Dislocations and subluxations of the calcaneo- cuboid, as well as incomplete dislocations in the astragaloscaphoid joint, have also been reported. Dislocation of the Small Tarsals. — Dislocation of the scaphoid alone and of one or more cuneiforms with their metatarsals has been seen. The dislocation was usually upward from direct violence or by falling upon the ball of the foot with the foot extended. For reduction only the general rule can be given to increase the size of the cavity from which the bone has been displaced. This will usually be accomplished therefore by forcibly extending the foot; the bones are then reduced by direct pressure. The dislocations of the small tarsal bones are so mani- fold that a short description is impossible. (Compare the literature given by Baehr. ) In the case of old dislocations a corresponding cavity can be hollowed out in the shoe, or, if very troublesome, the joint can be resected or the bone excised. Complicated and Compound Injuries in and about the Ankle-joint. — The occurrence and treatment of wounds complicating fractures and dislocations of the ankle-joint and tarsus have already been mentioned. The cases of comminution of the bones of the leg or ankle are more serious. Suppuration easily produces necrosis of the bones, involve- ment of one or more joints, and, as the tendon-sheaths are usually opened by the trauma, rapid transmission of the infection upward. The severe crushing injuries, due to direct violence, run-over accidents, etc., are even more serious on account of the possibility of immediate gangrene and necrosis, and of secondary infection from the rather com- mon uncleanliness of the skin of the foot. A foudroyant infection can develop very readily in the bruised tissues and spread rapidly through the bones, opened joints, and tendon-sheaths. It may even advance- rapidly to the production of a fatal malignant cedema. The unyielding- ligaments and fascia interfere seriouslv with free drainage and favor DISLOCATION OF THE TARSAL BONES. 767 suppuration. Recovery is therefore retarded and the function of the parts jeopardized by necrosis of the bones and protracted suppuration. Gunshot-wounds of the fool vary greatly; they may open the capsule of the ankle-joint without injuring the bone, or perforate the spongiosa of the tibia without involving the joint. But this is the exception, for as a rule the bones and joints arc both involved. If the trochlea of the astragalus is perforated, nol merely grazed, there are almost always fissures running into the various joints, so that if infection occurs the communicating joints arc also involved. Gunshot-wounds of the tarsus almost always affect several bones and joints, or involve the latter through fissures. The amount of comminution of the bones varies naturally according to the character and penetrating power of the pro- jectile. The more severe wounds produced by hand firearm-, and especially those produced by heavy ordnance, are very similar in char- acter to the compound fractures by crushing mentioned above, and are liable to be badly infected. (Septic Phlegmon.) Treatment. — Amputation is necessary primarily at the present time only in the severest cases of extensive comminution, but is required more often secondarily in acute septic phlegmon to save the patient's life. Small recent wounds are to be kept aseptic by careful cleansing and sterilization of the foot and application of a simple dressing. If the skin is undermined or endangered by the tension of an extravasation of blood, free incisions should be made to relieve tension, establish an outlet for the extravasate and discharge from the wound and facilitate the casting off of gangrenous sloughs. The incisions should be kept open and the cavities drained with iodoform gauze. If infection has already taken place, in addition to free incisions, the foot should be immobilized and elevated, or suspended in a splint extending above the knee. Or a fenestrated plaster-splint may be applied or the limb placed upon a double inclined plane. Whatever splint is used, the fixation of the foot at a right angle to the limb is very important in case ankylosis should follow, for if the foot becomes ankylosed in any other position, its use- fulness is seriously or even completely impaired. These general principles of conservative treatment are applicable to all injuries, including most of the gunshot-wounds. In field service, particularly in anticipation of transportation, the first dressing should insure proper immobilization of the limb, even if the cleansing and sterilization of the foot have to be incomplete and the dressing only provisional. Primary resection is necessary only when tire soft parts are severely injured, and then merely enough bone should be removed to insure free drainage. Secondarv resection is usuallv urgent as soon as infection occurs; one may first attempt to check the suppuration by free drainage, but in view of the unfavorable anatomical conditions, resection should not be delayed too long. v. Langenbeck's experience in the Schleswig- Holstein War of 1864 showed that even extensive resection of the tibio- tarsal joint could give good results. The formation of new bone fol- lowing resection for suppuration is very abundant and usually produces 768 INJURIES OF THE ANKLE AND FOOT. ankylosis. The after-treatment is very important in order to prevent a faulty position of the foot. Huter recommended total resection as a rule. v. Langenbeck preferred partial resection if possible, as it insured more fully the usefulness of the foot, a view held by most surgeons at the present time. The extent of resection is determined by the amount of splintering, the necessity for free drainage, and the measures required to secure a good position of the foot. If only the lower end of the tibia and fibula are involved, the astragalus is preserved as far as possible. If the astragalus is perforated, and, as usual, the suppuration involves the calcaneo-astragaloid joint, it should be removed. Even if all three bones are fractured and have to be removed, parts of the malleoli should be preserved if possible to insure the stability of the foot. In regard to the results of resection of the ankle-joint in war only the statistics of the preantiseptic period are available. Billroth estimated a mortality of about 35 per cent., Grossheim a mortality of 40 per cent, for total, and 30 per cent, for partial resection. Suppuration in the tarsus following injuries is even less influenced by simple incision and usually requires resection of several bones. The technic will be discussed later. INJURIES OF THE METATARSUS AND TOES. Fractures of the Metatarsals and Phalanges. — Fractures of the metatarsals are more common than was formerly supposed. They are usually due to direct violence, such as heavy weights falling upon the foot, and are associated with extensive wounds of the soft parts. If the skin is intact, a fracture is easily overlooked and the marked extravasation of blood referred to contusion until at the end of several weeks the persist- ent swelling and functional disturbance occasion a careful examination and callus is discovered. In recent cases accompanied by considerable swelling a positive diagnosis is only possible under anaesthesia or with the .c-ray. Especially by the aid of the latter have we been able to recognize the cause of a painful and formerly misinterpreted swelling of the foot, called tumor of the foot by Breithaupt, which was observed particularly in soldiers; it was referred to an inflammation of the tendon- sheaths, cf the deep ligaments, or to disease of the tarsometatarsal joints. With the x-tsly Schulte, Stechow, and Kirchner found that it was almost always due to a fracture of a metatarsal. These fractures were often produced by slight violence, for example, during a long march or by jumping, and at first occasionally produced so little disturbance that they were easily overlooked. In the majority of cases they were incom- plete — "green-stick fractures." In more than 90 per cent, of the cases the break was in the middle third of the second or third metatarsal; in a few instances in the fourth or fifth, and thus far never in the first. (Fig. 490.) Although by no means a rarity in civil practice, the con- dition is more frequently met with in soldiers, a fact upon which the weight of the knapsack has unquestionably some bearing. 1 S.I TRIES OF THE METATARSUS AM) TOES. 7G9 they should be for from two to Fig. 490. Prognosis.— The prognosis of fractures of the metatarsals depends upon the severity and number of the fractures. Those with extensive lesions of the soft parts always entail severe functional disturbance, although the simple fractures by indirect violence are liable to disable the patient for months or even permanently; in the very mild eases the period of recovery is from four to six weeks. Treatment. — If the fragments are much displaced, corrected by manipulation and the foot immobilized three weeks; later massage. Walking should not be permitted too soon, not before the fifth or sixth week, the same as in all fractures of the tarsals and ankle. Simple fractures of the phalanges are treated in the same way as those of the fingers. Dislocations of the Metatarsals and the Phalanges. — Dislocation in the tarsometa- tarsal joint, Lisfranc's joint, is very rare. One distinguishes total dislocation, in which all the metatarsals, and partial dislocation, in which single metatarsals are dislocated. In 1897 Panse collected 22 total and 23 partial dislocations from the literature, of the former the dorsal variety being most frequent. Total Dislocation of the Metatarsus. — Dis- location upward has been produced by falling from a height and landing upon the front of the foot, by falling and striking upon the extended metatarsus, by a heavy weight falling upon the tarsals, by which the same are driven downward and are not infre- quently fractured. The symptoms are very characteristic. The foot appears shortened, is slightly extended, while the toes are flexed. The arch of the foot is increased. Transversely over the dorsum pro- jects the line of the base of the metacarpals. Dislocation downward was seen only once by Smyly. (Lossen.) The mechanism is not known, but it is probably the reverse of that of upward dislocation. In Smyly's case the transverse line of the project- ing tarsals could be felt, and in front of it a deep groove; the metatarsus projected into the sole. The reduction of both forms is by traction and direct pressure. The mechanism of lateral dislocations is much disputed on account of the projection backward of the base of the second metatarsal beyond the other metatarsals in Lisfranc's joint. Malgaigne, Hofta, Lessen, and others assume that lateral dislocation is possible only after fracture or upward dislocation of the second metatarsal. This is true of the majority of cases. Dislocation inward, which has been seen only once Vol. III.— 49 Fracture of the second metatarsal. (v. Bergmann.) 770 INJURIES OF THE ANKLE AND FOOT. Fig. 491. (Kirk), is hardly conceivable without previous fracture of the second metatarsal. The possibility of outward dislocation can be understood from the obliquity of the sides of the second and third cuneiforms; Pan e admitted tins possibility. At any rate, fracture of the second metatarsal has been found in only half of the cases. Dislocation outward was usually produced by outward pressure upon the inner border of the front part of the foot while the heel was fixed, less frequently by violent adduction of the heel with the front of the foot fixed. Quenu regarded it as an outward rotation-dislocation, as he was able to produce it by forced extension of the front of the foot with inward rotation of and inward pressure upon the back of the foot. Diagnosis. — Lateral dislocations in Lisfranc's joint are easily recog- nized. If dislocated outward, the front of the foot is usually slightly abducted; the first cuneiform projects at the inner side of the foot, the base of the fifth metatarsal on the outer side. (Fig. 491.) If dislocated inward, the first metatarsal projects at the inner side, and at the outer side is a depression in front of the cuboid. Prognosis. — The prognosis is good if the dislocation is recognized and reduced in proper time. Treatment. — Reduction of lateral dis- locations is best effected by fixing the tarsus, increasing the dislocation by trac- tion and corresponding ab- or adduction and then adducting with lateral pressure for dislocation inward, and the reverse for dislocation outward. The foot should be immobilized for from two to three weeks. Dislocation of Single Metatarsals. — Dislocation of one or more metatarsals is generally upward, rarely downward. The first and fifth can also be displaced outward or inward. Treatment. — Reduction is by traction on the dislocated bone and pressure upon the projecting part. If unsuccessful, the joint is exposed, and if the bone cannot be replaced the end should be removed. The same applies to old dislocations. Even in case of non-reduction the foot becomes fairly useful. Dislocation of the Phalanges. — Dislocation of the toes in the meta- tarsophalangeal joints is rare; that of the hallux is most frequent and important. Upward dislocation of the great toe is the most common of the various forms, and is produced by extreme flexion; the head of the metatarsal is forced downward, tears the capsule, and slips out while the base of the phalanx slips over it. This presupposes great violence. The dis- Complete outward dislocation in Lis- franc's joint. (Panse.) Tx.jrniijs of Tin-: metatarsus and toes. 771 location is commonly received in jumping. The first phalanx lies Hexed upon the head of the metatarsal; the second phalanx is extended. The dislocation may be complete or incomplete; the head of the meta- tarsal frequently perforates the skin on the under surface. The hin- drances to reduction are the same as in the corresponding dislocation of the thumb. (Bartholmai.) Reduction is by increasing the flexion and then pressing the phalanx forward so that its base will push aside the interposed parts. Operative reduction is necessary for irreducible or old dislocations, eventually possibly resection. Even if unreduced, they give little trouble if a suitable shoe is worn. Dislocations of the hallux outward and upward, of which single instances have been reported, are apparently only variations of the above. Dislocation inward is produced by abduction of the toe. (Mal- gaigne, Notta.) In the few cases reported reduction was simple by traction and direct pressure. Fig. 492. Backward dislocation of the hallux. (Anger.) Dislocations of the four outer toes are commonly upward, and are entirely analogous to the corresponding dislocation of the great toe; one or more or even all five (Pailloux) have been dislocated. Josse reports a case of outward dislocation of all five by a fall from a horse. The very rare interphalangeal dislocations correspond to those of the fingers; they are more frequent in the great toe than in the others, and are com- monly upward. Hardly a dozen cases of dislocation of the terminal phalanx of the great toe are known and even fewer of interphalangeal dislocation of the other toes. (Broca, Riedinger, Styx.) From experi- ments, Riedinger assumes that upward interphalangeal dislocation of the four outer toes is only possible after lateral dislocation, and not by hyperextension alone. Reduction is by traction, with the aid of a slip-noose if necessary, and by pressure. Complicated Injuries of the Metatarsus and Toes. — The principles of treatment given for injuries of the tarsus are equally applicable to complicated injuries of the metatarsus and toes. The methods used at present in the treatment of wounds permit us to go very far in preserving injured parts. With reference to the foot, this conservatism can be carried too far, however. ^Ye should bear in mind 772 INJURIES OF THE ANKLE AND FOOT. that the loss of a toe (except the great toe, see chapter on Operations on the Foot) is of little or no importance, while primary amputation or exarticulation of a toe is of greater advantage to the patient than a poor stump saved at the expense of a long period of confinement. The same applies to severe complicated injuries of the metatarsus. Transverse amputation through the metatarsals gives excellent results, so that it is frequently preferable to conservative treatment. Good functional results require that the operation should be in sound tissues; the ends of the bones should be well padded with flaps of healthy tissues so constructed that the suture-line avoids the sole of the foot. The amputation is made squarely across and covered in with two flaps, a large plantar and small dorsal, or one large plantar flap. CHAPTER XXXVIII. DISEASES OF THE ANKLE AND FOOT. ACUTE AND CHRONIC INFLAMMATIONS OF THE OUTER SOFT PARTS. Acute Inflammations. — Acute inflammations are less common and less important in the foot than in the hand. Furuncle and carbuncle are rare and confined mostly to the dorsum of the foot and toes. Small ulcers, sometimes very painful, occur between the toes of people whose feet perspire and who wear tight shoes. This is also the favorite spot of other ulcerations, such as the papular syphilide, chancroid, and carcinoma. Small abscesses frequently develop under the epidermis ("subepider- moidal"), chiefly at points of pressure and in blisters or after slight wounds; occurring under thick callosities on the sole or under corns they can be very painful. The local swelling may be very slight, but associated with considerable oedema on the dorsum of the foot. The suppuration under callosities, etc., may spread beneath the skin into a diffuse cellu- litis. Usually, however, the process is in the reverse direction; a sub- cutaneous suppuration due to irritation or slight wounds perforates outward; sometimes the pus then spreads under the epidermis on the sole of the foot; the deep and superficial abscesses thus formed com- municate through a small opening in the cutis, and are comparable in form to a shirt-stud. On the dorsum such subcutaneous suppuration often follows a lymphangitis. If the process is in the sole of the foot, incision should be made early, as it can spread more easily beneath the aponeurosis than it can perforate the thick skin. Deep phlegmon under the plantar aponeurosis is often the result of injuries, small puncture-wounds made by splinters, needles, etc. Less frequently it is transmitted directly from the toes through the tendon- sheaths or lymphatics. The pain" is severe on account of the tension between the aponeurosis and the thick skin. The swelling and fluctua- tion in the sole of the foot develop more slowly than the swelling and redness on the dorsum, hence the frequent mistake made of incising on the dorsum. If the inflammation extends backward to the tendon- sheaths at the ankle, it is usually transmitted rapidly up the leg. Treatment.— The treatment of all these phlegmonous processes is early incision parallel to the nerves and tendons, and if possible at a point where the cicatrix will not be subjected to pressure later, so prefer- ably on the inner or outer border of the foot or in the arch of the sole. Chronic Inflammations.— Among the chronic inflammations of the soft parts should be mentioned several whose nature, whether inflamma- ( 773 ) 774 DISEASES OF THE ANKLE AND FOOT. tion, hypertrophy, trophic disturbance, or tumor, is still uncertain. Among these several forms of keratosis are important in minor surgery of the foot more on account of their frequency than for their surgical interest. A flat circumscribed keratosis is termed callosity, tyloma, or tylosis. According to Unna, it is essentially a thickening of the epider- mis with flattening of the layer of prickle-cells, and at first without hypertrophy of the papillae. If irritated for a longer time, the prickle- cells increase and the papilla? are lengthened. Clavus, or corn, is a more advanced form of induration with the thick- ening of the strata of prickle- and granular-cells around the edge and the hypertrophy of the papilla? shown by an irritated callosity. In the middle the conical core grows down into the corium, which atrophies and becomes indented. The pain is due to pressure upon the nerve terminals. Suppuration may develop under corns from small fissures or wounds and be very painful. A small bursa is often found under old corns. If it becomes infected and suppurates, the pain is intense. If the pus perforates outward, a small fistula is formed; the pain then subsides, but each time the opening closes the inflammation and painful retention recur. As the bursa occasionally communicates with the tendon-sheaths and joints beneath, the inflammation may spread to these. Although the common cause is the pressure of tight shoes, tylosis, and somewhat less frequently clavus, has been seen with- out previous long-continued traumatic irritation. Pitres and Vaillard found inflammatory and fibrous degeneration of the corresponding nerves of the foot in all cases of callosities; probably this was the result rather than the cause of the changes in the skin. The treatment is the wearing of proper shoes; small corns then usually disappear. If the corn is cut, the core should be removed thoroughly under aseptic precautions without causing bleeding. Some surgeons soak the corn before cutting; others state that it can be dis- tinguished from sound skin better if hard. The best way to soften a corn is to apply salicylic acid, either the plaster (empl. sapon. salicyl. 10-20 per cent.), the rubber plaster (30-50 per cent, salicylic acid), a 10 per cent, solution in collodion, or in substance. The corn often separates off of itself after these applications. Stronger cauterization is not advisable. Or instead a ring may be worn to protect it, facilitate its removal, and lessen the pain. The small bursa if opened during operation or suppurating should be opened freely or excised or cauterized. Tuberculosis of the skin and lupus are not uncommon on the foot. The former is usually confined chiefly to the skin and has no peculiarities in the foot. Lupus is found usually on the toes and dorsum. As in the hand, it is very often papillar (lupus papillosus or verrucosus) and superficial, and therefore easily cured by scraping and cauterizing with the actual cautery; but even this form may extend deeply. Lupus hypertrophicus, the form described as resembling epithelioma, with exuberant nodular growth of epithelium, is often found on the foot, as on the hand and arm. If it penetrates deeply, the fascia, tendons, periosteum, bone, and the joints may be gradually involved, and pha- DISEASES OF THE NAILS OF THE FOOT. 775 langes or even the toes cast off (lupus mutilans). Fusion of the toes and contractures may result from the cicatrization of the ulcers. If large areas are involved and the cicatricial contraction extends around the foot or leg, the bloodvessels and lymphatics become engorged and the foot greatly enlarged. This together with the nodular patches of lupus may produce great deformity. Scraping, cauterization, excision, and bandaging may improve the condition but never bring about recovery. Therefore amputation is sometimes advisable. Syphilis almost never occurs as a primary lesion in the soft parts. In a few instances we have seen a chancroid (ulcus molle) on or between the toes, transmitted by the fingers from an ulcer on the penis. Papular syphilides are not rare about the nails and between the toes. The sole is a favorite site of the squamous syphilide (psoriasis plantaris syphil- itica). It may be confused with tylosis if associated with callosities and fissures. Occasionally it is very painful. Gummatous syphilides, serpiginous ulcers, and deep gummata also occur on the foot. The latter if broken down but not yet ulcerating may be confused with abscess. Leprosy of the foot is rare in Germany [and America]. (See A. v. Bergmann in Deutsche Chirurgie, Lieferung Nr. 10b). Madura foot (mycetoma, fungus foot of India) is a disease of the foot endemic in India but rarely met with in Germany [or America]. It is a chronic purulent inflammation of the foot, beginning in the soft parts, burrowing throughout the entire foot, and destroying the tendons, bones, and joints. The pus contains black, yellow, and white granules, similar to but larger than those of actinomycosis, so that Tusini has recently regarded the condition as being a genuine actinomycosis. In the first stages conservative measures, incision, scraping, and excision, are apparently indicated; but later amputation, if the foot is thickened or honeycombed. The similarity of the two diseases has been emphasized recently by Bollinger, who reports a case of genuine actinomycosis of the foot which started in the skin, but did not produce any extensive destruction of the bone until several decades later. Ainhum or spontaneous dactylolysis, is the term applied to a spon- taneous amputation of the fingers and toes which is met with most often among African negroes. Most frequently it affects the fifth toe, less so the fourth, and never the other toes. Only one instance of this sort is known among Europeans. (Wiedemann.) [Herrick (Philadelphia Medical Journal, February 5, 1898) describes the case of a negro who had lived in Illinois thirty years (cited by Hyde, 1900), and Crocker (1903) a case of Johnson Smith at the Seamen's Hospital, Greenwich, England.] DISEASES OF THE NAILS OF THE FOOT. Only a few of the diseases of the nails are of surgical interest. Onychogryphosis. — Of the trophic disturbances, the severe forms of onychogryphosis, in which there are enormous growths similar to the 776 DISEASES OF THE ANKLE AND FOOT. lioofs and claws of animals, may occasionally demand removal of the nail. These deformities are seen most frequently on the great or little toe of elderly people, but also occur on the other toes. Niigeli reports very large cornifications on all ten toes. These growths are caused chiefly by the pressure of the shoe, but once started the deformivy increases after the irritation has ceased. Treatment. — The growth should be softened in a bath of potassium carbonate, and then cut off and the nail filed down smooth and covered with an impervious rubber plaster to prevent drying. (Heller.) If the condition is painful, the nail can be extracted. The other trophic dis- turbances of the nail due to nervous or general skin diseases or parasites are not surgical. Onychia and Paronychia. — The acute and chronic forms of onychia and the acute forms of paronychia are the same in the toes as in the fingers, but much less frequent. (See Diseases of the Wrist and Hand.) Onychia maligna is a term applied to a peculiar chronic ulceration of the matrix occurring in the toes as in the fingers. It is probable that it is generally tuberculous, but in regard to obstinate ulcerating processes about the nails one should bear in mind that the recovery of such ulcers can be prevented by the constant irritation of the shoe and uncleanliness. The papular syphilides and the ulcers which are found especially at the edge of the nail, occasionally horseshoe shape around the nail, are to be sharply distinguished from onychia maligna. Treatment. — In all obstinate cases the nail should be extracted, as it prevents drainage and irritates the ulcer constantly. Its loss is less important than on the fingers. The tuberculous onychia should be scraped out thoroughly and burned with the actual cautery if it does not yield readily to conservative treatment (lead nitrate, antiseptics). Clavus Subungualis. — Clavus subungualis is a condition that is fre- quently overlooked; it makes walking and standing very painful, and should always be thought of unless the pain is referable to ingrowing toenail. The results of treatment, splitting or extracting part of the nail and removing the callosity, are very grateful. Ingrowing Toenail. — Ingrowing toenail (onyxis, onychia, ony- chauxis, onychogryphosis, unguis incarnatus) is a very common con- dition affecting most frequently the outer border of the great toe, less so the inner border or both sides of the nail, and rarely the other toes. The free edge and side of the nail press against and irritate the skin, which becomes inflamed, swollen, and gradually thickened around and over the edge of the nail. Then the nail-fold or mantle suppurates, granulations form, and the process advances backward, although rarely extending to the upper part of the nail-fold. The entire toe may become swollen and lymphangitis develop. The pain may be so severe that the patient cannot wear a shoe and even without it have to favor the foot. If the nail is curved sharply sideways, or flat and bent sharply at the lateral edge, or movable with its free edge extending far back, it favors the development of the affection; also if the toe is broad and the skin grows up at the sides and in front. Short and narrow DISEASES OF THE NAILS OF THE FOOT. 777 shoes are the immediate cause, by pressing the skin against the nail. The second toe is sometimes forced under the first and presses the skin upward and laterally against the nail, so it has been recommended to bandage the second toe upon the first or to separate them. The fact that the condition also occurs in bedridden patients and is seen ehienV in younger persons indicates a certain predisposition of the tissues. Improper paring of the nails is a very significant cause, as known; if the nail is cut too far back or unevenly, the sharp edge easily irritates the skin. Standing or walking for a long time in tight shoes, trauma, frostbite, etc., combined with the bacteria usually present in the skin are the causes of inflammation and suppuration. The nail is passive in the process, the skin being rubbed against it, irritated, and infected. The prophylaxis is well-fitting shoes and proper care of the nails. The side of the nail should project beyond the skin in front. Treatment. — Attempts have been made to separate the nail from the nail-fold by placing pieces of lead, iron, tin-foil, lint, gauze, etc., between them. Iodoform gauze is better, and should be renewed until the ulceration has healed and the nail has grown out beyond the affected spot. The granulations are cauterized. Removing a triangular piece from the edge of the nail may help to allay the irritation till the spot has healed. In order to lift up and cut off the nail more easily, it has been shaved or filed off, or painted or swabbed with a 1 :4 solution of potassium carbonate, or caustic potash, or collodion or traumaticin (gutta-percha 10, chloroform SO) Fig. 493 painted on between the nail and the granu- lations. The skin may be pressed away at I the same time by means of a small pad fast- I ened on with adhesive plaster. Operation is preferable for severe cases or for recurrence. Of the various methods of Temoving the nail or the soft parts, or both, few are satisfactory. The frequency of re- currence demonstrates the necessity of remov- ing part of the matrix with the nail and skin. It should be remembered that the nail and its matrix extend beyond the lunula and the skin-fold. The simplest method and the one in general use in Germany is to make a lateral curved incision below the ulcerated skin (Fig. 493), and extending about § inch back of the nail-fold. From this latter point a straight incision is made directly for- ward through the nail; the included skin, nail, nail-fold, and matrix are excised, being careful not to leave any matrix or nail at the side or upper angle. The edge of the skin is then applied and held by the dressing against the edge of the nail. Unless considerable skin has been removed on account of ulceration, and in the absence of infection, the patient is usually about in S days. The operation can be performed under cocaine with a small tourniquet applied around the toe above. Anger inserts 778 DISEASES OF THE ANKLE AND FOOT. the knife above the mantle, makes a straight incision forward along the side of the nail or in sound skin, retracts the skin-flap thus made and removes a portion of nail and matrix and all diseased tissue, and then sutures or binds the flap back in place. Recovery is supposed to be rapid and permanent. Quenu, proceeding on the assumption that the nail only grows from the upper part of the matrix, extracts the nail and then excises a rectangular piece from the upper part of the matrix and covers in the exposed area with a small skin-flap. Dardignac recommended this method. In order to excise the matrix with greater ease and certainty, he dissected back a somewhat broader skin-flap. If the nail is ingrowing on one side only, a piece of the matrix can be removed on the affected side, but if on both sides, the matrix is excised straight across. The results are supposed to be good ; the growth of skin over the defective area of the matrix is sufficiently resistant to prevent discomfort, even when the entire nail is absent. Baumgartner prefers to- preserve the bed and matrix intact and therefore simply removes the nail. DISEASES OF THE TENDON-SHEATHS AND BURS.S OF THE FOOT. Diseases of the Tendon sheaths in the Foot. — The diseases of the tendon-sheaths of the foot are less important than those of the tendon- sheaths of the hand. In the toes the sheaths are especially subject to acute suppuration after injuries. As the arrangement of the flexor sheaths is the same as in the fingers, any inflammation in them can spread rapidly to the metatarsals and after perforating through the sheaths spread through the sole of the foot. All other forms of acute and chronic inflammation are of slight importance. Tuberculosis of the sheaths is seen occasionally. The sheaths of all the tendons about the ankle-joint except the tendo Achillis are well developed and inflam- mations of the same are more important. Anatomy. — The tendon-sheath of the common extensors of the toes begins about 2 inches (according to Hartmann 2h inches) above a line connecting the tips of the malleoli, and ends about 1 inch below this line over the middle of the third cuneiform. In its upper half it is cov- ered by reinforcing fibres of the crural fascia, the so-called ligamentum transversum cruris. Between the lower border of this ligament and the ligamentum cruciatum cruris the sheath is covered merely by very thin fascia for a distance of about \ inch. From this point it extends another 2 inch downward beneath the fascia on the dorsum. Effusions in the sheath can therefore distend the same mainly at two points; below the ligamentum cruciatum — that is, just below the line of the malleoli, and between the ligamentum cruciatum and transversum above this line. Any distention is usually visible first at the former point, although in many instances it appears at both places, in which case through-fluctua- tion can be obtained beneath the ligamentum cruciatum. The sheath of the extensor hallucis begins about 1^ inches (according to Hartmann f inch) above the line of the malleoli, and usually extends DISEASES OF THE TENDON SHEATHS AND BURS^E OF FOOT. 779 to the base of the first metatarsal, exceptionally farther forward. In its upper portion it is covered by the Ligamentum transversum, in its middle portion by both arms of the ligamentum erueiatnm, and the last V inch is covered only by fascia. Effusions therefore cause distention chiefly at the lower end at the level of the base of the first metatarsal, ami of somewhat long oval form; but bulging may also occur in the short intervals between the two arms of the ligamentum erueiatum and between the ligaments erueiatum and transversum. The sheath of the tibialis amicus begins 2 inches above the line of the malleoli (Hartmann 2\ inches), and is covered in its upper portion by the ligamentum transversum, in the middle by the upper arm of the liga- mentum erueiatum, and its lower portion lies between this arm and the lower arm of the same ligament, which latter passes over the tendon below the end of the sheath. The sheath is therefore more easily dis- tensible in its uncovered portion between the two arms of the ligamen- tum erueiatum at the level of the tibiotarsal joint. The tendons of the two peronei have a common sheath which divides into two about H to 2\ inches (Hartmann, If to If inches) above the tip of the external malleolus, these in turn extending to a point h inch above the tuberosity of the fifth metatarsal. According to Hartmann, the sheath of the peroneus brevis extends to the level of Chopart's joint, and that of the peroneus longus to the groove in the cuboid. If the common sheath is distended by chronic effusions, etc., the swelling is of elongated spindle shape and chiefly behind and above the malleolus. It may also bulge between the retinacula peroneorum or at the anterior end of the sheath at the front part of the calcaneum. In the sole of the foot the peroneus longus has a sheath separate from the other tendon sheaths, but with walls so thin that in the event of suppuration perfora- tion easily occurs in either direction. The tendons of the tibialis posticus, flexor longus digitorum, and flexor longus hallucis are separated from each other by fibrous septa. The sheath of the first of those muscles begins 3 to 3 V inches (Hartmann, 2\ inches) above the tip of the internal malleolus. Near the insertion of the tendon the sheath is tucked in like a bursa between the tendon and the scaphoid, while the broad medial surface of the tendon is attached to the fascia. The sheath of the flexor digitorum begins about lh inches (Hartmann, the same) above the malleolus and extends to the astragaloscaphoid joint. The sheath of the flexor hallucis begins f inch above the tip of the malleolus and extends slightly farther into the sole. The sheaths of the flexor hallucis and flexor digitorum often communicate where they cross each other. Effusions in the sheaths behind the malleolus are most prominent above the ligamentum laciniatum (internal annular ligament), less frequently below at the inner border of the sole, but are never very distinct on account of the firmness of the overlying parts. Acute inflammations more frequently affect the sheaths of the exten- sors and peronei than those of the flexors situated behind the internal malleolus. Acute dry and crepitant or mild serous tenosynovitis occurs 780 DISEASES OF THE ANKLE AND FOOT. after severe exertion, such as long marches, etc.; or as the result of rheumatism. If neglected, it may become chronic. Gonorrhceal tenosynovitis not infrequently develops in the sheaths of the extensors, flexors, and peronei; the joint is often uninvolved. With proper treat- ment the prognosis is good. Suppuration is almost always by trans- mission from a suppurating wound or cellulitis. After the sheath ruptures the suppuration spreads easily into the deep fascia of the leg in front or behind, according to the position of the tendon. Of the chronic serous effusions, aside from those resulting from acute trauma, rheumatism, or gonorrhoea, the tuberculous is the most important. It occurs in the form of a hygroma with or without rice- bodies, and also as the fungous variety. The tendon-sheaths of the peronei are the ones most frequently affected. A tuberculous hygroma is almost always easily diagnosed, aside from the etiology. The fungous form, especially in the sheaths behind the malleoli, may present diffi- culties. Where the form and extent of the swelling correspond to the limits of the sheaths as described above, they are often quite character- istic, but the tuberculous process is not always limited; occasionally it extends into the loose tissues in front of the tendo Achillis or higher up in the leg. Secondarily it may involve the bones and joints, but the usual process is in the reverse direction; in the case of the peronei the calcaneum is generally the primary focus. Treatment. — The acute and chronic forms of tenosynovitis usually yield rapidly to compression and rest and leave no stiffness if appropri- ate massage is employed. Suppuration requires free incision. In the tuberculous forms iodoform may be injected, but operation is often found necessary. The latter consists of free incision and scraping, or, better, thorough excision of the tuberculous tissue, and later injection of iodoform. Diseases of the Bursae. — Views differ as to the constancy of numerous small bursas in the foot aside from the one between the tendo Achillis and the tuberosity of the calcaneum; this Hartmann regards as con- stant. In at least a large number of cases other small bursa 3 are found and they become important by reason of pathological changes, espe- cially the "accidental" bursa? which develop beneath the skin over bony prominences as the result of constant pressure of shoes, etc. The bursa achillea anterior or retrocalcanea has recently been the subject of closer study. (Rossler.) Diseases of the same are frequently due to trauma, single or repeated attacks of gonorrhoea, less frequently articular rheumatism, gout, influenza, and syphilis; tuberculosis of the bursa is usually secondary by transmission from the calcaneum. Dis- ease of this bursa is sometimes evidenced by a fluctuating tumor of some size, but more frequently by the presence of a small swelling beneath the insertion of the tendo Achillis, which feels like a thickening of the tuberosity of the calcaneum. In the gonorrhceal form the swelling may involve the adjacent soft parts and periosteum of the calcaneum. Chronic diseases of the bursa, in addition to producing thickening of the sac, may cause an actual growth of the periosteum, which Rossler ACUTE INFLAMMA TI0N8 OF JOINTS AND BONES OF FOOT. 781 has compared to the process in arthritis deformans. The patients generally complain of more or less severe pain in walking, which may radiate into the calf. The effort to relax the tendo Achillis apparently leads to the production of flat-foot. Treatment. — The treatment of acute bursitis of the retrocalcaneal bursa is antiphlogistic, especially resl and pressure; of chronic bursitis, application of moist hot compresses and massage. Eventually aspira- tion and irrigation if necessary; if still unsuccessful, incision and irri- gation with carbolic acid, or packing with iodoform gauze to obliterate the bursa, or excision. If tuberculous, the bursa should be excised. If necessary the tendo Achillis may be divided and sutured at the end of the operation. Some of the French authors maintain that the painful swelling of the heel in gonorrhoea is characteristic (pied blennorrhagique); that it is due to a periostitis and ostitis of the calcaneum, and especially to involve- ment of the insertion of the tendon on the calcaneum. We believe, however, that it is the bursa which is usually affected and that the swelling and induration of the surrounding soft parts — eventually the periosteum — merely resemble disease of the bone. At any rate, the latter is much less frequent than the bursitis. In v. Bergmann's clinic we recently saw a case of this sort, which finally required operation after months of treatment; the thickened and almost completely obliterated bursa was excised and the flat mass of new bone projecting backward from the calcaneum was chiselled off with a good functional result. It is possible that the tenderness on the surface of the calcaneum which is not infrequently found in gonorrhoea is due to periostitis at the insertion of the tendon. Or it may be that the bursa subcalcanea is diseased. The author once excised a diseased bursa of this sort with thickened walls. The bursa achillea posterior, which lies between the tendon and the fascia and above its insertion, is also affected by the same diseases, but rarely. Of the small inconstant bursa?, those on the metatarsals and toes, especially the metatarsophalangeal bursa?, are the ones most fre- quently affected. Ganglion is a very rare condition in the foot and occurs almost exclusively on the dorsum over the articulations of the cuboid. Its treatment is the same as that of ganglion of the wrist. ACUTE INFLAMMATIONS OF THE JOINTS AND BONES OF THE FOOT. Inflammations of the Tibiotarsal Joint. — As a rule acute effusions in the tibiotarsal joint first distend the front part of the capsule at the sides of the extensor tendons. If the soft parts are not much involved, the swelling is very sharply defined and gives fluctuation. Later it appears on the posterior surface of the joint and below the malleoli. In acute inflammations the soft parts are usually oedematous and red. The slightly extended position which the foot commonly assumes in the 782 DISEASES OF THE ANKLE AND FOOT. recumbent position, or when the limb is suspended, is due largely to the weight of the forepart of the foot. Any great destruction of joint-surfaces is rare in acute inflammations or occurs late, even in the case of suppu- ration, unless the latter starts in the bone. On the other hand, the tendon-sheaths about the joint are often involved early. The acute effusions which follow fractures and sprains of the foot are generally hemorrhagic, rarely serous from the start; later a chronic serous synovitis is apt to develop rather frequently after such injuries. The suppuration of the joint following penetrating wounds, fractures, and dislocation has already been mentioned. The other purulent processes are chiefly due to suppuration spreading from an acute osteo- myelitis of an adjacent bone or from a phlegmonous process — especially of the tendon-sheaths about the joint; they may occur also by pysemic metastasis. Acute articular inflammations occur in a number of infectious diseases. The joint is frequently affected in rheumatism, often previous to the involvement of other joints. Gonorrhoeal arthritis is a very frequent occurrence; the condition is characterized by intense pain, usually marked swelling of the soft parts, frequent involvement of the tendon-sheaths, and great tendency to the development of ankylosis. Treatment. — Conservative treatment consists essentially in the appli- cation of slight compression and complete immobilization of the joint. It is important to remember that unless properly immobilized the foot is apt to become extended, and that almost all inflammations of the ankle-joint are very liable to be followed by adhesions and shrinkage of the capsule. The impending limitation of motion can be prevented and overcome, to some extent at least, by appropriate mechanical treat- ment if supported by energetic exercise on the part of the patient; nevertheless many joints become permanently stiffened. In inflamma- tions of the ankle-joint the foot should therefore never be left free, but should be immobilized in strip splints or plaster, care being taken that the foot is at a right angle to the leg and in the mid-position between inversion and eversion. If the ankle-joint becomes ankylosed in any other position, it almost always compromises the use of the limb. The existence of suppuration is indication for immediate incisions at either side of the extensor tendons in front, and also behind the joint if necessary. As the structure of the joint prevents free drainage, the incision should be kept widely open. Oilier recommended removing part of the malleoli subperiosteally through posterior incisions to give better drainage. If the suppuration is from osteomyelitis, it usually suffices to open and clean out the focus and drain the joint through a free incision. If free drainage is not obtained, part of the joint should be resected, the astragalus rather than the malleoli, according to Oilier. Or, as in Konig's method, the articular ends of the tibia and fibula may be removed and the malleoli and astragalus, or parts of the same, preserved if possible. It is only in the very severe cases, however, in which necrosis of the separated epiphysis of the tibia is certain, that one would decide to remove subperiosteally the entire articular surfaces of ,:> the tibia and ACUTE INFLAMMATIONS OF JOINTS ANT) BONES OF FOOT. 783 fibula. Osteomyelitis of the astragalus is very rare. The bone should be removed it' exposure and drainage of the focus and incision of the ankle-joint are not adequate; also if the mediotarsal joint is involved. Suppuration of the Joints and Bones of the Tarsus. — Acute suppu- ration of the joints and bones of the tarsus occurs most frequently after puncture and incised wounds, compound fractures or dislocations, or by transmission from a phlegmon of the soft parts. It is also seen as the result of metastasis in pyaemia, osteomyelitis, gonorrhoea, etc. The affection is apt to be transmitted rapidly from one joint to another on account of the numerous communications, and to involve the entire tarsus and tibiotarsal joints. The only exception to this is in the case of osteomyelitis of the calcaneum, as will be seen later. The tendon- sheaths are easily infected, and can thus transmit the phlegmonous process upward into the leg. The limb then becomes swollen throughout, the skin red and oedematous; usually the foot becomes adducted, inverted, and extended. As the effusion is always under pressure on account of the firmness of the ligaments the pain is severe, the fever high, and the articular surfaces and bone are rapidly destroyed. Early incision is therefore urgent. The anatomical conditions are against free drainage; simple incisions of the joint can only be made on the dorsum and on the sides of the foot, as in the sole the tense soft parts make drainage very difficult; so it often becomes necessary to resect portions of the tarsus. The latter measure will be undertaken even more promptly where the suppuration originates in the bone, as in acute osteomyelitis, for as a rule the bone rapidly becomes totally necrotic in this case and always demands early partial or complete removal. The calcaneum has rather a unique position in this respect as it is the most frequent site of osteomyelitis of all the tarsal bones, and the pus perforates more commonly outward than into the joint, in contrast to the same process in the other bones. The suppuration may be limited to the posterior portion of the bone, but may still involve the calcaneo- astragaloid joint, or the whole bone may be infected and necrotic, in which case the adjacent joints are usually involved. The characteristic swelling in the heel below the malleoli is accompanied early by inflam- mation of the soft parts, and severe pain makes the diagnosis simple in acute cases. In subacute cases, or if seen late in the acute stage, when necrosis and fistulas are present, the differentiation from tubercu- losis may be difficult. Treatment. — The treatment consists in chiselling out all diseased bone as early as possible through a curved outer incision, the same as for resection or excision of the calcaneum. If this does not check the process, one may wait for demarcation and a new growth of periosteum to take place; the latter is very important for the later function of the foot. If the joints of the calcaneum, especially the calcaneo-astragaloid, are involved secondarily, or if the whole bone is necrotic, it should be excised. Acute Inflammations of the Bones and Joints of the Metatarsus and Toes. — Ajute inflammations of the bones and joints of the metatar- 784 DISEASES OF THE AXKLE AXD FOOT. sus and toes are most frequently due to injuries, phlegmon, and ulceration of the soft parts. Acute suppurative osteomyelitis of the metatarsals seldom attacks the toes, but, on the other hand, is generally associated with disease of numerous other bones. Acute articular rheumatism sometimes attacks these joints, also gonorrhoea. In the latter case there is usually marked swelling of the joints and surrounding soft parts, and the process is very painful and stubborn; it may be confused with other acute inflammations, especially attacks of podagra. In the course of the infectious diseases periostitis and osteomyelitis of the metatarsals are occasionally seen, which, if subacute or chronic, produce swelling and oedema of the dorsum that present a picture similar to the so-called "tumor of the foot." (See Fractures of the Metatarsus.) A diagnosis is possible only by careful examination and longer observation. Treatment. — Suppuration of the metatarsals and toes is treated on general principles. If the tarsometatarsal joints are affected, the suppu- ration may extend to the tarsus. If suppuration of the joints is not checked by incision and drainage, the joints may have to be resected or the toes amputated. In general it is more important to preserve the great toe than the others, so that resection is preferable in this case to amputation if possible. In the case of the other four toes the decision is made more readily in favor of amputation or exartieulation. Suppu- ration is more commonly met with in the metatarsophalangeal joint of the great toe than in the others. Good results can be obtained if the sesamoid bones and head of the basal phalanx can be preserved and enough of the articular surface of the metatarsal left to give support to the head. Suppurative osteomyelitis of a metatarsal is treated as usual: free incision, preferably on the dorsum, exposure of the sequestrum by chiselling, and removal. In case of suppuration or necrosis involving the entire metatarsal, the question of preserving the toe depends again upon whether it is the hallux or one of the other four that is affected. In children amputation of the four last metatarsals and toes is advisable if the epiphyses of the lower ends of the metatarsals and the phalangeal joints are suppurating, because the cicatricial contraction and disturb- ance in growth produce shortening, atrophy, and contractures that are later very troublesome and generally necessitate removal of the toes. On the other hand, one always hesitates to remove the great toe because of its importance. So conservatism is indicated, particularly when the upper epiphysis of the metatarsal can be saved, as it is apt to produce a fairly adequate amount of new bone. CHRONIC INFLAMMATIONS OF THE BONES AND JOINTS OF THE FOOT. Chronic Rheumatism. — Chronic rheumatism not infrequently affects the phalangeal joints and leaves a certain amount of stiffness. In the ankle-joint it is more serious, as it may produce a troublesome contrac- ture if the position of the foot is neglected. Gonorrhoeal arthritis in the CHRONIC INFLAMMATIONS OF BONES AND JOINTS OF FOOT. 785 tibiotarsal and metatarsophalangeal joints (especially the first) is often followed by a chronic deforming inflammation if the patient walks too soon or if then- arc frequent attacks. Arthritis Deformans. ---Arthritis deformans of the ankle-joint is most frequently met with after injuries of the joint, such as fractures of the malleoli, etc. It occurs also in old people without apparent cause. In the tarsus and toes it is very often the result of deviations or contractures of the joints, such as hallux valgus, pes valgus, etc.; hut without such local causes it is more rare. Treatment. — The surgical treatment of the above affections is limited chiefly to overcoming the deformity and contracture. Severe pain may necessitate resection, or amputation in the case of the toes. Gout. — Gout (arthritis urica, podagra) is of greater importance. Its favorite points of attack are the joints of the toes, particularly the 1 Metatarsophalangeal joint of the hallux. Its chief significance for the surgeon lies in the fact that it is not apt to be mistaken for other forms of joint inflammation. The attacks are characterized by a more or less intense inflammation and swelling of the joint and surrounding tissues, which often begins suddenly and subsides gradually at the end of several days. Frequently repeated attacks are followed by a permanent deposit of uric acid and urates in the cartilage and capsule of the joint and surrounding soft parts. In the latter there are sometimes nodular deposits of uric acid containing material resembling chalk (gout nodules, tophi). The deposits may exist for a long time without producing any severe disturbance. Occasionally they break down, suppurate, and lead to the formation of fistulas. Treatment. — The treatment of gout and its attacks belongs to medi- cine and the internist. The local treatment of attacks is limited to attempts to alleviate the pain, elevation of the limb, inunctions, envelop- ment in cotton or moist warm compresses. In many cases cold com- presses or the ice-bag give comfort. Morphine is at times indispensable. The veteran "podagrist" usually takes care of the attacks himself and has certain favorite internal remedies. Against surgical measures, such as incision — occasionally made on a wrong diagnosis — the warning should be given that they are never beneficial and often do harm. The only provocation for surgical interference is suppuration in a very diseased joint filled with large urate deposits, due to ulceration of the overlying skin. This is frequently the case in the great toe. Resection of the joint may be attempted, but in elderly people amputation of the toe is preferable. Large urate deposits in the soft parts may be excised or scraped out with the sharp spoon if they become troublesome by reason of their size or situation or if they suppurate. Stiffness of the joint, contracture, ankylosis in a faulty position, or subluxation may occasionally require surgical treatment. Syphilitic Affections. — The syphilitic inflammations of the bones and joints of the foot are of less importance and show few variations in com- parison with the local manifestations of syphilis elsewhere. The various Vol. Ill —50 786 DISEASES OF THE ANKLE AND FOOT. forms of joint syphilis are much less frequent in the tibiotarsal joint than in the favorite sites, the knee and elbow. In the tarsus, hyperostoses may occur in the congenital form, and gummatous processes later in life in the acquired form of syphilis. Dactylitis syphilitica is the same process in the toes as in the fingers; it occurs in the congenital and late in the acquired form of syphilis. The periostitis or central ostitis which pro- duce the tumefaction of the bone may disappear spontaneously or lead to suppuration and necrosis. Effusions also occur in the synovial cavities with swelling of the articular ends of the bones. In children it may be difficult to distinguish the disease from tuberculous spina ventosa, espe- cially as congenital syphilis and tuberculosis are often found coexistent. The treatment is specific. Necrotic bone should be removed. TUBERCULOSIS OF THE JOINTS AND BONES OF THE FOOT. Tuberculosis is the most important of the chronic inflammations of the bones and joints of the foot. It also has a conspicuous position in the scale of frequency of joint tuberculosis in general. Frequency. — Billroth and Menzel give tuberculosis of the skeleton of the foot sixth place in order of frequency of joint tuberculosis. A few more recent authors give it second place with disease of the skeletal trunk first. The value of such statistics is limited as they vary with the material from which they are derived. The same applies to the data with reference to the site of the original focus in tuberculosis of the foot. Mondan's statistics of 117 cases examined at operation or post-mortem in Ollier's clinic give 114 primary osseous, 31 primary synovial, and 25 cases of doubtful origin. Among the 114 primary osseous cases: the calcaneum was diseased in 40, the astragalus in 29, tibia 14, fibula 2, cuneiforms 5, metatarsals 5, cuboid 4, scaphoid 3, and in 12 several bones simultaneously. The small number of primary synovial cases in these statistics is due to the fact that the cases of purely synovial tuberculosis heal more easily than those due to large osseous foci, and so come to autopsy less frequently. The number of cases of disease of the metatarsals and toes is small because they are based upon clinical observations and are therefore the cases to which little attention is paid as they are mostly ambulant. Tuberculosis of the foot develops and spreads differently according to its site, so that an anatomical classification is of a certain clinical value. Tuberculosis of the tibiotarsal joint in the greater majority of cases starts primarily in the bone, occasionally at several points, and most frequently in the astragalus. Small foci are also found under the car- tilage or at the margin of the synovialis in the tibia and fibula; if the joint is greatly destroyed, they are easily overlooked in operating and the condition regarded as primary of the synovialis. Large foci with or without a sequestrum also occur in the epiphysis of the tibia, less often in the fibula. (Fig. 494.) The tibiofibular joint is rarely intact TUBERCULOSIS OF THE JOINTS AND BONES OF THE FOOT. 787 if the disease b: of longer standing. 'The process spreads easily to or from the calcaneo-astragaloid joint; it can also spread forward and completely surround the tarsus with diseased tissue. In 71 cases operated upon by Oilier the primary focus, according to Vallas, was in the astragalus in 22, the calcaneum in 13, the scaphoid in 3, the cuboid in 1, in the fork of the malleoli in 9, and in the syno- vialis in 23. The small number of primary synovial cases is possibly also explained here by the statistics being taken from only the severe and therefore operated cases. Riedel, who operated upon every case of tuberculous arthritis of the foot as soon as the diagnosis was estab- lished, found the percentage of primary synovial cases only a trifle higher, namely, 36 per cent. Among 907 cases compiled by Hahn from Fig. 494. Tuberculous sequestrum of the tibia. (Kiinig.) various statistics (Audry, Konig, Mondan, Munch, Spengler, Vallas) and the material of v. B runs' clinic there was 31 per cent, of primary synovial tuberculosis and 68.7 per cent, of primary osseous tuberculosis. In 74 cases the origin was indefinite. If the process spreads beyond the joint, abscesses and fistulas are found most frequently at the outer side of the extensor tendons, less so below the malleoli or at either side of the tendo Achillis. The suppu- ration may extend along the tendon-sheaths and perforate outward at some distance. The sheaths behind the malleoli are involved somewhat more frequently than those in front. Symptoms. — The first symptom of tuberculosis of the ankle-joint is the effusion ("hydrops of the joint "). At the onset there is a soft swelling 788 DISEASES OF THE ANKLE AND FOOT. of the synovialis with some pain in the joint, producing a slight limp; this swelling appears first at the sides of the extensor tendons, later under the malleoli and behind; it varies, however, with the position of the osseous focus. The joint is usually extended, adducted, and inverted slightly, but movable, later becoming more fixed. If the mediotarsal joint is involved, the foot is often adducted and inverted at an early period. There is rarely any great displacement of the joint-surfaces upon each other, as the astragalus is held firmly between the malleoli; slight lateral and sagittal mobility is possible if the ligaments and bones are destroyed. The pain on motion and tenderness are two of the first symptoms. They may be very severe, or slight even when the joint is greatly swollen. Fever may be absent as in all cases of tuberculosis of the joints, and slight in connection with suppuration unless phlegmon occurs or the limb is moved more actively. Diagnosis. — The differentiation of tuberculous from rheumatic or syphilitic joint, the joint of long-standing gonorrhceal arthritis, the swelling of painful flat-foot, and the rarer acute inflammations or central tumors of the bones, will depend chiefly on the history and general point of view. Tuberculosis of the tendon-sheaths is usually recognizable by the position and irregular outline of the swelling, which does not sur- round the joint. If the two conditions are coexistent, it may be difficult to determine whether we are dealing with the one or the other, or both. It is also difficult to detect whether the disease has spread to the cal- caneo-astragaloid joint, that is, whether both or the upper or the lower of the joints of the astragalus are affected. If the calcaneo-astragaloid joint alone is affected, the swelling lies chiefly below the malleoli, passing. over the upper part of the calcaneum; if the tibiotarsal joint is simul- taneously involved, swelling is also present around and in front of the malleoli. The astragalus, of which the body is more often diseased than the neck, is supposed to give characteristic localized swelling and pain at the outset, but as one of its joints — most frequently the tibiotarsal — is usually involved soon after or simultaneously, the diagnosis is uncertain except where all three of its joints are involved at the same time. In 170 cases of tuberculosis of the astragalus in v. Brains' clinic the ankle- joint was intact in only 8, and in these the focus was in the neck, the head, or the under surface of the body. (Halm.) The calcaneum has a unique position. It is the most frequent site of tuberculosis of all the tarsal bones, and is apt to contain large sequestra. The foci may be situated below and behind the sinus tarsi (Fig. 41).")) or in the posterior process and spread forward, especially in children; or behind, under the insertion of the tendo Achillis and perforate back- ward; or there may be a diffuse caseous degeneration or almost total sequestration of the bone. In the majority of cases the process is confined to the bone without involving the joint. (Mondan gives 26 cases of joint involvement in 40, and in v. Brims' clinic there were 87 in 200 of tuberculosis of the calcaneum.) Perforation takes place most frequently TUBERCULOSIS OF THE JOINTS AND BONES OF THE FOOT. 789 outward or outward and downward, much less so inward or backward. The calcaneo-astragaloid joint is the one most often concerned in the few cases of joint-involvement (according to Mondan only 14 cases in 40); the tnediotarsal is next in frequency. Abscesses and sinuses arc then more frequently met with on the inner side of the foot or at the sides of the tendo Achillis. The calcaneocuboid joint is seldom attacked. If the soft parts arc involved, the tendon-sheaths of the peronei are Fig. 49.5. Fig. 496. Tuberculous foci in the os calcis. (Finotti.) more apt to be affected than the flexors on the inner side, but in the latter case the process is liable to spread into the sole and become more serious. The symptoms of tuberculosis of the calcaneum are very characteristic in many cases. The surrounding soft parts are swollen and the bone itself is thickened, suggesting a tumor or osteomyelitic necrosis. The swelling lies below the malleoli. The more it is limited to the heel, the easier is the diagnosis of disease of the calcaneum alone. In such cases Konig has more frequently found the sinuses leading to the tuberosity and a diseased area near the tendo Achillis, whereas Wiesinger has 790 DISEASES OF THE ANKLE AND FOOT. found the bursa achillea involved. We have rarely seen this condition without joint-involvement. If the calcaneo-astragaloid joint is involved, the swelling extends higher toward the malleoli and eversion and inver- sion are painful. A positive diagnosis of disease of this joint is hardly possible, however. In the small anterior tarsal bones and their joints the disease is more apt to be limited to the inner or outer side of the foot if the scaphoid or cuboid alone is affected. But generally the process in the anterior tarsals is distinguished by the fact that it extends rapidly over the area between Chopart's and Lisfranc's joints, often attacking the anterior articular surfaces of the astragalus and calcaneum; and in front, the bases of the four last metatarsals. The disease may start in one of the latter. The first metatarsal and its articulation with the first cuneiform is seldom involved unless this joint communicates with the others, but it is often diseased alone. The two synovial sacs situated between the four last metatarsals and the tarsus are less distinctly shut off from each other, so that the process often spreads rapidly across Lisfranc's joint. It also meets with little resistance in passing to or from the tarsus. As the swelling spreads rapidly and uniformly over the foot between the mediotarsal and tarsometatarsal joints, it is impossible to determine the site of the primary focus after the disease is advanced. If suppu- ration occurs, it is apt to perforate on the dorsum or at the sides. Ab- scesses in the sole usually attain considerable size under the tense fascia before perforating. In severe cases the swelling is spindle-shaped between Chopart's and Lisfranc's joints, often with many fistulas. The foot is extended; the front part of the foot is extended, adducted, and often also inverted. In the metatarsals and toes tuberculosis usually appears in the form of spina ventosa in children, as in the metacarpus and fingers. The disease is often multiple. In adults the joints and articular ends of the bones are more frequently affected, usually the metatarsophalangeal joint and metatarsal of the great toe, less frequently the fifth metatarsal or the other bones and joints. The frequency of tuberculosis in the bones of the foot is given by Halm from the statistics of 1231 cases as follows: calcaneum, 26 per cent.; astragalus, 24 per cent.; cuboid, 13 per cent.; scaphoid, 9 per cent.; cuneiforms, 9 per cent.; metatarsals, 9 per cent.; malleoli, 8 per cent.; and phalanges, 2 per cent. Treatment. — The treatment of tuberculosis of the tarsus and tibio- tarsal joint should be conservative at the beginning of the disease, except where there is positive evidence of the existence of a large osseous focus, as, for example, in many cases of tuberculosis of the calcaneum. Few surgeons would advise operating in every case involving the ankle-joint as soon as the diagnosis is made, for a considerable number of these recover without operation, especially in youth. The principles of conservatism are the same as applied to tuberculosis in general. In the absence of any great amount of suppuration, rest and Tl'UKIKTI.nsiS OF THE JOINTS AND BONES OF THE FOOT. 791 fixation with moderate pressure, and finally elevation when there is much swelling, are most effectual. As usual, the foot should be fixed at a right angle to the leg and in the mid-position between eversion and inversion, the only proper position in ease ankylosis follows. A well- fitting plaster-splint is the best, though strip splints or removable fixation apparatus may be used. Rest and immobilization of the joint are best assured by the recumbent position. Children do well in bed, even for a long period. Hut some do better to be about, as in the case of adults, as soon as possible. If the ordinary fixation splints and apparatus are worn crutches have to be used, as the former do not take the weight off of the ankle-joint. So the ambulant splints are better which make walking possible without encumbering or disturbing the foot. This can be accomplished by means of the simple plaster-splint if it is supported firmly against the tuberosities of the tibia; the sole of the foot is well padded with cotton, or, better, an iron foot-brace is incorporated in the plaster, extending half an inch or more below the foot, and the other foot raised with a thick sole. Of the removable apparatus, the best are those made in two parts, the lower like a high, tightly fitting laced shoe, and the upper having a brace to bear against the tuberosities of the tibia or the tuber ischii. In addition injections of iodoform glycerin, etc., may be used at the same time. They seem to act favorably in the foot. The ankle-joint can be injected at the sides of the extensor tendons, and other joints and abscesses at appropriate points. In regard to other methods, such as passive congestion, which could easily be combined with ambulant treatment, the author has had no experience. When and how long to attempt conservative treatment is a difficult question. In children even suppurative and fistulous tuberculosis occa- sionally heals under fixation and iodoform glycerin injections without operation or possibly after scraping out or opening up the fistulas and abscesses. If the child's general condition is good, the author advises conservatism. Immediate operation is only indicated in the cases of profuse suppuration, often accompanied by fever, and especially in those in which large osseous foci are suspected or demonstrated, as in numerous cases of tuberculosis of the calcaneum. If after several w r eeks of conservative treatment no improvement occurs, the general condition becomes worse, or evidence of tuberculosis appears in the inner organs, operation is necessary. Maas in Konig's clinic advises operation after the treatment has been tried for two months; this applies to children. In adults the prospect of recovery by con- servative treatment is slight, so that the appearance of suppuration is positive indication for operation. In children the abscesses and sinuses may be incised and scraped out successfully; but in adults these procedures are often followed by exacer- bation and rapid involvement of the adjacent joints, tendon-sheaths, and soft parts. Therefore it is imperative in adults to remove thoroughly all tuberculous tissue by free exposure and careful dissection of the diseased area. Arthrectomy, resection, or even amputation may be necessary. 792 DISEASES OF THE ANKLE AND FOOT. There is not yet any unanimity of opinion as to the time for resection or amputation. In general the indications for resection have been greatly extended in the last ten or twenty years, and the results of resec- tion are much better than formerly. This is mainly due to the fact that we no longer dread the bad functional results of extensive resection that previously often made surgeons hesitate to remove the tuberculous tissues thoroughly. We know to-day that even after very extensive resection for severe cases of tuberculosis recovery is more rapid and the usefulness of the resulting foot is satisfactory, in fact even better than after partial amputation. The most radical methods, which secure the removal of all diseased tissues and thereby prevent recurrence, seem to us to be the best, for they ensure the quickest recovery and allow the patient to be about in the least time. The latter consideration is important, as the danger of recurrence, especially for older patients, lies in the long period of convalescence and the decrease in general strength thereby entailed. The question as to resection or amputation is decided somewhat by the local condition, but more particularly by the strength of the patient to endure a long period of convalescence. This depends upon the general condition, and especially upon the age of the patient. Isler found that the mortality of resection up to the fifteenth year was 5 per cent., from the twentieth to the twenty-fifth year 10 per cent., and later 19 per cent.; the younger the patient the better was the functional result. As to resection or amputation in general, advanced age is an indication for amputation. Rapidly progressing or extensive tuberculosis of the lungs or other organs, amyloid degeneration, and great weakness are counter- indications to resection, although even with these conditions the results in younger individuals are occasionally unexpectedly favorable. The various methods of operation will be found under operations on the foot; only the more important will be discussed here, and those applicable to certain special regions of the foot. The operative treatment of tuberculosis of the ankle-joint has nothing to distinguish it from the treatment of disease of the two posterior tarsal bones, as the joint is almost always involved with the latter, except in the cases of primary tuberculosis of the calcaneum. The old resection methods of Bourgery and v. Langenbeck are not suitable, as they do not give a good view of the diseased area, sacrifice too much bone from the leg, and endanger the usefulness of the foot, for in tuberculosis the growth of new bone often remains insufficient. Konig's method gives a better view of the joint than most of the other methods with anterior or posterior longitudinal incisions, unless one removes the astragalus according to Yogt and Oilier; it also preserves the malleoli, but does not facilitate the removal of the synovialis behind. For this reason v. Brims adds two longitudinal incisions at either side of the tendo Achillis. Riedel's modification of Konig's method is also valuable; also the curved outer incision of Kocher and Lauenstein. By the latter method the joint can be dislocated and the capsule exposed throughout and excised without "resecting any bone. If the process extends on the inner side of the foot toward the astragalonavicular joint or involves TUBERCULOSIS OF THE JOINTS AND BONES OF THE FOOT. 793 the soft parts and tendons, Konig's method is better, or the anterior transverse incision of Heyfeldcr and Sedillot recommended by I Inter. Honssev's anterior curved or flap incision can be used to even better advantage, particularly if the process extends over the front of the tarsus, as it gives a good view of the ankle-joint, and, if necessary, the entire tarsus. The function of the tendons is also more readily restored the farther forward they are divided, even when they are not sutured. The wound can therefore be packed with iodoform gauze for a long time. In general, however, in view of their being the least conservative, the anterior curved and transverse incisions should be reserved for very severe cases. As to the advisability of attempting to procure a movable but stable joint after arthrectomy or resection — this is undoubtedly the more ideal result and one which is most feasible if the malleoli are preserved. But the possibility of recurrence is greater in a movable joint, so that in the author's experience ankylosis is in general better assurance against recur- rence and more conducive to definite recovery. Among 102 resections in Konig's clinic recorded by Maas: of 11 operated upon by v. Langenbeck's method, only 1 case recovered with a useful joint; of 87 operated on by Konig's method, in 48 of which the astragalus was removed, 42 were examined later; they all had a useful joint without looseness or deformity of the foot. The shortening was 3^ to Sh inches in contrast to 5| inches by v. Langenbeck's method. If the process is confined chiefly to the posterior part of the tibiotarsal or the calcaneo-astragaloid joint and spreads out at the sides of the tendo Achillis, the methods of Szabanejew and Bogdanik are best. The astragalus can also be removed by these methods. If the disease is limited to the posterior calcaneo-astragaloid joint, Oilier advises a bilateral V-shaped flap-incision with base above, one side of the V in front of the tendo Achillis, the other parallel to the inner and outer borders, respectively, of the foot. Foci in the calcaneum are best removed from the outer side even when the fistulas open on the inner side. In children the focus can be exposed through a horizontal incision and scraped or chiselled out. The cavity gradually fills in of itself. If the foci are very large it is better, espe- cially in older people, to remove the lateral wall of the cavity and implant the soft parts. For this purpose, a curved or angular incision on the outer side is best, as employed for removal of the calcaneum. If in addition the astragalus and the calcaneo-astragaloid and tibiotarsal joints are diseased, both bones may demand excision (posterior tar- sectomy). Often the under surface of the calcaneum is intact (v. Bruns, Kuttner), for example, when the calcaneum is involved secondarily from the astragalus or the focus lies nearer the upper surface. In this case the lower surface should be preserved ; v% Bruns' resectio tibiocal- canea may be used with advantage. In all resections of the posterior tarsal bones the integrity of the sole of the foot should be preserved if possible. The osteoplastic resection of Wladimiroff and v. Mikulicz is necessary only when the soft parts and skin of the heel are destroyed or filled with fistulas. 794 DISEASES OF THE ANKLE AXD FOOT. In the anterior part of the tarsus, if the disease is limited to single bones and joints, as, for example, to the cuboid, first cuneiform, and first tarsometatarsal joint, or to the scaphoid, partial resection may be sufficient, and can be performed through a longitudinal incision at the side or on the dorsum of the foot. This is advisable, however, only in youthful patients. If the process is more extensive, even though it does not involve the whole width of the foot, it is better to resect the entire transverse portion (anterior tarsectomy). This is especially advisable in older individuals, because the growth of new bone is inadequate to prevent troublesome deviations of the foot, furthermore because radical removal of the diseased tissue is urgent. The metatarsals and toes are less essential parts of the foot, and may be removed more radically, for, if preserved, the resulting deviation and contracture are liable to be troublesome later. In children expe- rience has shown that spina ventosa has been little influenced by injection of iodoform. Hence if suppuration occurs, operation is indis- pensable. In adults the conditions are even less favorable, so that operation is indicated at the outset. If the tarsometatarsal joints become involved, they should be resected, possibly with the metatarsals, or in children scraped out with a sharp spoon. If the epiphyseal lines of the toes are destroyed, it is better to remove the toes, except in the case of the great toe, which should always be preserved if possible. In older patients one has to choose between leaving part of the front por- tion of the foot, with the possibility of recurrence, and amputation. Tuberculosis of the metatarsophalangeal and interphalangeal joints in children should be subjected if slight to thorough scraping or resec- tion, otherwise amputation or exarticulation is preferable. In adults, amputation is almost always better, except again in the case of the great toe, whose metatarsophalangeal joint is a spot of choice for tuberculosis; here resection should always be tried at first unless rendered impossible by extension of the disease, above all by the general condition and advanced age of the patient. Widely as we are able to apply conservatism in the operative treat- ment of tuberculosis of the foot, there always remains a considerable number of cases in which conservatism fails or is contraindicated by the extent of the process or the advanced age or poor condition of the patient. Amputation is then necessary. No rules can be given as to the choice of methods of amputation or exarticulation. One thing is important: to operate in sound tissues and not be too sparing of a portion of foot or leg. In these cases everything depends upon the prevention of recurrence and upon rapid recovery. In not a few very extensive cases of tuberculosis of the foot resection has been made to include portions of the anterior section of the tarsus beside the two posterior tarsals, or the entire tarsus with the exception of the lower surface of the calcaneum. In fact, the tarsus, with or without the articular surfaces of the tibia and fibula, has been removed. Yet the use of the foot was often very good. Various incisions were used; long inner or outer longitudinal, or transverse. The most prac- CONTRACTURES AND DEFORMITIES OF THE FOOT. 795 tical incision for such atypical resections is a large anterior flap-incision. The usefulness of the fool was largely due to new hone formation. As stated above, it is therefore advantageous to preserve pari of the cal- caneum, either the periosteum, tuberosity, or lower surface, although even without it the fool can be useful. CONTRACTURES AND DEFORMITIES OF THE FOOT. Contractures and the deformities which result from them are fre- quently met with in the foot; they are of greater significance here than in any other part of the body. While in the other joints the contrac- tures of arthritic origin — that is, due to inflammatory changes in the joint — are in the majority, their importance is slight in the foot com- pared to those due to a number of other causes. A large group of deformities of the foot are congenital, the result of faulty embryonal construction, or of external forces producing faulty position and development in utero of the normally constructed foot. Congenital club-foot is an example of this type of deformity. The other main group consists of those forms acquired later in life. Among these belong the cases of arthrogenous contracture and ankylosis which are followed by other contractures due to cicatricial contraction of the soft parts, for example, the talipes equinus caused by cicatricial retraction of the calf muscles. Also the deformities due to over- or faulty weighting of the foot and the wearing of improper shoes. Flat- foot is the most common example of this type. There is also a large and important class of contractures due to neurotrophic disturbances. Before describing the various forms of contractures it will save repetition to discuss paralytic contractures and the aims of treatment in the differ- ent varieties of deformities of the foot. Mode of Origin of Paralytic Contractures. — The development of para- lytic contractures has been explained for a long time by Delpech's theory of antagonistic muscular action. When one group of muscles is paralyzed, the healthy antagonists by reason of their muscular tone draw the limb to their side and so into a contracture position. This theory was opposed by Werner in 1851, but first disproved satisfac- torily by Hiiter and v. Volkmann. They showed that contracture fol- lowed paralysis of entire as well as single groups of muscles, and that it was due essentially to mechanical influences, the weight of the foot, and encumbrance of the same. They went too far, however, in entirely disregarding the contraction and elasticity of the muscles. Seeligmuller recognized these factors, so the explanation of contracture is now antag- onism and mechanical action. The healthy muscles in contracting give the limb a position which is maintained unless mechanical factors act upon the foot, as the paralyzed muscles are not able to combat the shortening of the sound muscles which is at first voluntary, but becomes permanent by reason of their inherent elasticity. This leads to shrinkage of the sound muscles. As a rule external mechanical forces act upon 796 DISEASES OF THE ANKLE AND FOOT. the foot in the same or opposite direction to the action of the healthy muscles. In the latter case the mechanical action is usually stronger than that of the sound muscles. In order to make clear the influence of gravity and encumbrance upon the foot, which is of such importance in order to understand all other non-paralytic contractures, we will assume that all the muscles are paralyzed. The weight of the foot then comes into play when the foot is not used in walking or standing, as has been shown especially by Hiiter. In the recumbent position, or with the foot dependent, as in sitting or walking with crutches with the limb drawn up, the part of the foot in front of the rotary axis of the ankle-joint is heavier than the shorter part behind, so the front drops and the heel rises (talipes equinus). But the disposition of the weight of the foot and the axis of motion in the mediotarsal joint combine also to adduct and invert the foot, so the foot is almost always in a position of combined talipes equinus and varus — that is, paralytic talipes equinovarus. At the outset the foot can be easily carried over from this position to the opposite one, but unless the plantar flexors are opposed by mechan- ical action, they gradually shrink while the dorsal flexors become stretched. In the same way the ligaments and fascia shrink on the concave surface and stretch on the convexity. Thus the abnormal position becomes a fixed one and the contracture is complete. Finally, changes also take place in the bones and joints; the cartilages are apt to disappear where they are no longer in contact and new cartilage forms on the opposite side of the joints, so that the latter become shifted or even new joints are formed; the form and structure of the bones change to meet the demands of altered pressure. All these factors further increase and fix the contracture. The above results of the action of the weight of the foot occur not only in paralysis of the foot, but at all times when the muscles which influ- ence the position of the foot are thrown out of action voluntarily or otherwise. For example, in injuries or inflammations of the bones, joints, muscles, or tendons about the ankle, if the muscles are weakened or their activity is arrested, or if the patient prevents their action to avoid pain, or is kept in the recumbent position for a long time by severe and weakening illness. The development of a contracture is then favored by still other mechanical causes, such as the weight of the bed-coverings, etc. The significance of the peculiar disposition of the weight of the foot therefore exceeds that of the paralytic contracture, and should always be thought of in connection with all of the above-mentioned forms of disease of the foot. Unfortunately it is often impossible, although so simple, to prevent the development of a contracture by appropriate exercises or splints. So many a patient suffers unneces- sarily for the carelessness of his physician in being temporarily or even permanently disabled. Under certain conditions the action of gravity upon the completely paralyzed foot is opposed by bearing the weight upon it. When stand- ing or walking the weight of the body upon the foot causes it to become COXTJtACTl'RES AM) DEFORMITIES OF THE FOOT. 797 flexed and at the same time abducted or everted in direct opposition to the action of gravity. As the plantar flexors and invertors arc par- alyzed, eversioD and dorsal flexion are only checked by the bones and ligaments. But these gradually give way and the foot becomes over- flexed, everted, and abducted — that is, in the talipes calcaneovalgus posi- tion. Hut as the foot is extended by the action of gravity every time it is raised from the ground and when the patient is lying down, the result is an abnormally loose ankle-joint (flail-foot). If, however, as is often the ease, a certain degree of talipes equinovarus contracture develops before the foot is used, then the patient cannot place the sole flatly in walking, but bears the weight on the outer edge of the foot. This causes the foot to become more and more adducted and inverted in the same way that it is acted upon by the force of gravity, until a high- grade talipes equinovarus develops. Assuming now that one group of muscles is paralyzed, for example, the dorsal flexors, while the antagonists, the plantar-flexors, are still active : with the first attempt to move the foot it will be extended by the plantar flexors and remain so under the influence of gravity so long as the patient is recumbent or the foot hangs down. Thus muscular action and gravity work together and a contracture will develop early. If the foot is used in walking, this action may be combated; but usually the encumbrance increases the equinovarus contracture, as the latter often exists before the patient begins to walk. When the plantar flexors are paralyzed and the dorsal flexors are intact, as Seeligmuller has shown, the foot becomes flexed and may be fixed in this position (talipes calcaneus) as the result of the shortening of the dorsal flexors unless the action of the plantar flexors is effected by mechanical forces. This is usually what happens, the action of gravity extending the foot as soon as the dorsal flexors are relaxed. A talipes calcaneus contracture seldom develops if the patient does not walk or stand. As soon as the patient does walk the weight of the body forces the foot into the talipes calcaneovalgus position. As in total paralysis of the foot, this position seldom becomes fixed, however, because the foot is always extended by gravity when suspended or in the recumbent position. These examples may suffice to explain the varying action of the forces working upon the paralyzed foot to produce contractures or not, as the case may be. We shall have occasion later to discuss many modifica- tions of the contractures mentioned and combinations of the same; also the action of the various mechanical forces and the individual types of paralysis. Treatment of Contractures. — The aim of treatment in the different contractures will vary according to the mode of origin of the deformity and the causes of the impaired motion. In a large number of cases, in which the motor apparatus is essentially intact in spite of the exist- ence of contracture, we are very often more or less successful in restor- ing the full use of the limb by operative or orthopaedic measures. In others we have to be satisfied with partial results. To the latter class 798 DISEASES OF THE ANKLE AND FOOT. belong the large group of paralytic contractures. Overcoming the con- tracture does not mean that the patient is cured, for it returns gradually as soon as treatment ceases. So throughout the rest of their lives the patients have to wear orthopaedic apparatus replacing the action of the paralyzed muscles by means of elastic bands or springs, or at least preventing the evil results of the functional loss. As this method of treatment is always troublesome and a trial and pecuniary burden to the patient, especially among the poorer classes, the effort to supplant it or make it less burdensome by other procedures CONTRACTURES AND DEFORMITIES OF THE FOOT. 799 is justifiable. There are two modern operative methods which have this purpose in view, namely, arthrodesis and tendon transplantation. By means of arthrodesis the contracted or abnormally movable foot is transformed into a still' natural stilt; by tendon transplantation the < Uoit is made to replace the action of the paralyzed muscles by group- ing the intact muscles so as to maintain the foot in its normal position and prevent contractures from developing. Without any question the purpose of the latter method is more nearly ideal. Tendon transplan- tation was first employed by Nicoladoni to overcome a pes calcaneus due to paralysis of the calf muscles ; since then the method has been developed by Drobnik, Vulpius, Hoffa, Lange, and others, and made applicable to all spastic and total paralyses and their sequelae. Of the various modifications of the method the following are most useful: 1. Functional transfer. The healthy muscle is divided and the proximal stump sutured to the paralyzed muscle or its tendon. (Fig. 497.) As the original function of the muscle is thus destroyed the method can be used only when the sound muscle can be dispensed with. 2. Functional division. (Fig. 498.) (a) The distal stump of the paralyzed muscle is sutured to the sound muscle, (b) A flap of sound muscle is sutured to the paralyzed muscle. This is the better method. Periosteal tendon transplantation, as proposed by Lange, has the advantage of using only intact, healthy muscle without employing the Fig. 499. Shortening tendon by "gathering." atrophied tendon. For example, in paralytic talipes varus with the peronei paralyzed and the tibialis anticus intact, the tendon of the latter is split and the outer half sutured to the periosteum of the cuboid. The muscle thus overcomes the pathological position and also has a new function. (J. Wolff's osteal tendon transplantation has no apparent advantage over the above method.) The plan of operation should be worked out carefully in every case; often a long and accurate examination is necessary to determine which muscles are paralyzed or weakened, which are active. The electrical reaction of the muscles is indispensable in connection with the test of their active mobility for the purpose of determining the availability of the various muscles for any plan of operation. In- spection of the muscles at the time of operation gives no definite infor- mation as to their power of regeneration. The correction should always be excessive, as the atrophied tendons stretch in time. 800 DISEASES OF THE ANKLE AXD FOOT. As a rule transplantation is combined with other operations on the tendons (lengthening or shortening). The tendon is lengthened best by Bayer's Z-shaped section. Shortening is effected by dividing the tendon transversely and overlapping the stumps, or by Lange's method of ruffling the tendon. (Fig. 499.) In v. Bergmann's clinic the tendons are sutured with sterilized silk, the skin with catgut, and a circular plaster-splint applied and left on for three weeks; later, massage and exercise. Tendon transplantation is advisable only when there is a pros- pect of obtaining a result which makes any other than very light appa- ratus unnecessary. Otherwise, at least among the poor, arthrodesis is preferable. The success of transplantation in many cases depends upon long and exacting after-treatment. The after-treatment of arthrodesis is slight and simple. Talipes Varus [Pes varus, equinovarus, pied hot varus, piede varo, Klumpfuss]. — The term talipes varus [club-foot of the author] is applied to every faulty inversion position of the foot maintained under abnor- mal conditions. (Bessel-Hagen.) Physiologically inversion is accom- panied by a certain amount of adduction and extension. In talipes varus the physiological limit of adduction and extension of the foot is usually exceeded, but as this is not constant it must be regarded merely as an associated condition. In general, only those deformities can be designated as talipes varus which are permanent. The so-called "varus position" is an adventitious curvature occurring temporarily in certain forms of arthritis or with temporary muscular contraction, but under certain circumstances it may become permanent. Etiology. — Of the two main types of talipes varus, congenital and acquired, the former comprises, according to Bessel-Hagen, 74 per cent., the latter only 26 per cent, of all cases. Of congenital talipes varus, we distinguish after Bessel-Hagen a primary or idiopathic, and a secondary variety. The former is due to faulty construction of the embryonal trace or arrested development; the latter to the action of mechanical forces upon the normal foot in utero. Study has shown that primary talipes varus is rare. Although the primary and secondary forms are not sharply divided, the distinction is useful in discussing the patho- genesis. Among the primary forms belong those with defect of an important bone; most frequently the tibia. Absence of one or more tarsals, sometimes with deficiency of the toes, syndactylia, and anomalies of the muscles, have also been recorded. Some of these are due to faulty construction of the embryo, others to arrested development. To arrested development Bessel-Hagen also attributes the anomalies of the muscles, faulty insertion of the muscles and of the fundiform ligament, and the cases of embryonal talipes varus in which there is a well- developed joint between the fibula and calcaneum. In talipes varus due to arrested development there are elements resembling those found in the lower orders of the phylogenetic evolu- tionary series; for example, the oblique direction of the long neck of the astragalus, which is found in the orang-outang, and to which atten- CONTRACTURES AM> DEFORMITIES OF THE FOOT. 801 tion was called by Parker and Sliattoek; also the extended position of the two posterior tarsals, found in the foot of digitigrade mammalia. But it would be wrong to attribute such apparent similarities, which are also found in secondary talipes varus, to atavism. Many of the peculiarities of the talipes varus type of arrested development point to a continuation of an even earlier stage. Bessel-Hagen's conception of these relations differs entirely from the earlier generally accepted views. Dieffenbach at first maintained that the newly born always came into the world with talipes varus of the first degree. Esehrieht tried to show that the foot was even more strongly inverted earlier in foetal life than in the newborn. The lower extremities were supposed to be rotated in the beginning so that their posterior surfaces lay against the abdomen with the little toes side by side. Then, as the extremities grew, they became twisted in the long axis and in a spiral direction. If the lower end of the extremity escaped in this torsion process, the foot grew in this anomalous position and became a talipes varus. This theory, once defended by Volkmann, has been recently brought forward again, slightly modified, by Berg. Hiiter proceeded on Dieffenbach's assumption that normally the foot of the newborn was inverted. He tried to prove this by the differences which he and Adams found in the normal foot of the foetus, newborn, and adult. By comparing talipes varus with the normal foot of the newborn he was led to assume that talipes varus was a pathological exaggeration, as it were, of the physiological inversion position, due to excessive development of the bones and joints of the foetus in certain directions corresponding to this inversion position. Bessel-Hagen's investigations, the results of which agreed with those of Scudder, showed that this theory was based on false premises. Bessel- Hagen affirms that the torsion of the extremity does occur, but not uni- formly or to the same extent always, and that it does not influence the position of the foot with reference to the limb; also that in talipes varus the limb is almost always rotated inward; while, according to this theory, it ought to be twisted outward, as in sympus a pus. From his investiga- tions concerning the relation of the foot to the limb during embryonal life he agrees entirely "that the embryonal foot is normally markedly extended, but that it gradually becomes more flexed without the develop- ment meanwhile of any pronounced so-called physiological varus position. To be sure, there is as a rule a very slight deviation in the sense of adduction, but simultaneous inversion is extremely rare." The results of these investigations are confirmed by other authors, so that Esehrieht and Berg's torsion theory seems to be disposed of. Also Hiiter's theory, as there is therefore no stage of development in which the inversion or varus position would be a physiological one. The ana- tomical similarity which, according to Hiiter, exists between the bones in talipes varus and in the newborn, can in fact be referred to a large extent to individual variations, and are therefore unimportant. In fact the anomalies in talipes varus are not always in the direction of exaggeration of normal foetal forms, but often just the opposite. For Vol. III.— 51 802 DISEASES OF THE ASKLE AXD FOOT. example, the posterior portion of the calcaneum deviates inward from the long axis of the astragalus more in the normal foetus than in the adult, while in congenital talipes varus it deviates outward. According to Bessel-Hagen's theory only the extended position of the two posterior tarsals in primary talipes varus due to arrested develop- ment can be explained by a reversion to an earlier stage of development. He explains the rare congenital talipes equinus in this way. The rarity of these forms is easily explained by the fact that in the extended position Fig. 500. \ < .„..?' Fig. .501. Vfcs$ Position of the feet in utero. (Banga.) the foot is subjected to a greater extent to the action of external me- chanical forces (uterine pressure, etc.), which obviously tend most fre- quently to invert the foot. Bessel-Hagen does not deny the influence of pressure in primary talipes varus, but still regards the inherent peculi- arities of the foot as the dominant factor in its production. As stated, these peculiarities are supposedly the flattening of the corpus tali and anteroposterior convergence of its sides, the deviations of the insertions of ligaments and tendons, and the existence of a calcaneofibular joint. The author cannot regard these changes as characteristic of arrested L'OSTRAVTUllES A XI) DEFORMITIES OF THE FOOT. 803 developm* nt nor attribute all these deviations and displacements to the period in which the muscles, tendons, ligaments, and joints are being formed. He believes instead that capsule insertions and tendons can become shifted and abnormal joints be formed later in intrauterine life under the influence of mechanical forces which produce faulty positions. The author further believes that the only safe conclusion which can be drawn from such displacement is, that talipes varus develops at a rela- tively early stage, and that it is still impossible to determine whether it is caused by arrested development of the joints, ligaments, and tendon insertions, or secondary changes due to mechanical forces. The occurrence of primary idiopathic talipes varus is verified by the fact that this and other primary deformities are inherited. The occur- I'h.. 502. Fig. 503. Interlocking of the feet. (Volkmann and Vogt.) rence of congenital talipes varus in several children of the same family does not exclude the agency of external mechanical causes; but such causes cannot be assumed in the cases in which talipes varus is inherited from the father or mother or repeated through three generations, or transmitted from the first to the third generation. The secondary cases are more numerous; their production in utero by external forces was taught by Hippocrates and Galen. Only recently has the influence of abnormal pressure been studied and verified. Sometimes the attitude of the fcetus in utero can be determined from the position of the feet and limbs and the deformity of the feet. (Figs. 500 and 501.) One or both feet may be in the varus position, or one varus and the other a talipes calcaneus or calcaneovalgus ; in the latter case the feet are often interlocked. (Figs. 502 and 503.) The pressure- 804 DISEASES OF THE ANKLE AND FOOT. marks on the skin, first described by v. Volkmann, are even more positive evidence of mechanical influence. These spots are small, glossy, almost round, the skin atrophic and covered with only a thin layer of epidermis; the papillae, sweat and sebaceous glands are absent, and a small bursa may replace the subcutaneous fat; the marks are found on the prominences — e. g., external malleolus — which are exposed to the pressure of the uterus or the fcetal body. The pressure necessary to produce talipes varus must naturally be greater than the physiological energy of growth of the foetus; it is not so great, however, as that required to limit movements of the foetus and check the full development of the muscles. Nor does it have to be continuous. It suffices that the foot is held inverted in the intervals of rest. The abnormal conditions essential to the production of talipes varus are attributable to the uterus and to the foetus. In the former case they are adhesions between the amnion and foetus, rarely from the foetus becoming entangled in the umbilical cord, and most frequently insufficient space. The latter is probably due less to lack of distensibility on the part of the uterus than to a relatively insufficient secretion of liquor amnii. This lack of room also explains the coexistent contractures sometimes seen in other joints, for example, club-hands. The effect is increased if the position of the limbs is faulty; this explains, for example, the coexistence of congenital contractures or dislocations of the hip- and knee-joints and talipes varus. Tumors of the uterus, numerous pregnancies, bilateral deformi- ties, and twins can also decrease the intrauterine space. K. Roser assumes that the foot is twisted by striking the uterus obliquely during its movements. This is true for some cases. The conditions attrib- uted to the foetus are, improper position of the limbs, faulty construction of the primitive trace, contractures and dislocations of the knee and hip, foetal rhachitis (rare), diseases and defects of the central nervous system with congenital paralyses (hydrocephalus, rhachischisis and spina bifida, encephalocele and anencephalus). The fact that talipes varus occurred in connection with these forms of paralysis was turned to account in defence of the theory that talipes varus in general was due to muscular and nervous disturbances, a theory relinquished some time ago. That the talipes varus associated with congenital paralysis is not due directly to the results of the paralysis, but to mechanical forces, is attested to by the pressure-marks seen in these cases and the fact that the feet are reciprocally deformed, for example, the coexistence of talipes varus of one foot with valgus of the other, or of genu valgum with genu varum ; also the occasional existence of only one talipes varus in complete paralysis of both limbs. The acquired form may develop immediately after trauma, fractures of the malleoli or the tarsals, dislocations in the tibiotarsal or medio- tarsal joint, or dislocation of the astragalus alone. The deformity is naturally increased if the foot is used in the abnormal position, and may become very marked and permanent. Much more frequent than the above immediate or primary forms of acquired club-foot are the secondary forms, which do not follow imme- CONTRACTURES AND DEFORMITIES OF THE FOOT. 805 diately after the causal disease or condition, 1 > 1 1 1 are produced by the action <>f deforming forces whose activity first comes into play as a result of the causal condition. Part of these cases may be termed static talipes varus. If the leg is held strongly abducted, as, for example, in genu valgum, the sole of the foot cannot be planted squarely on the ground unless the foot is inverted. If the altered line of pressure thus established is continued, the temporary abnormal position may become fixed and permanent, although rarely reaching a high grade. It may develop similarly if the lower third of the leg is curved sharply outward, or the outer border of the foot is lower than the inner, or the foot is inverted, as, for example, in fractures of the leg uniting with deformity or less frequently in rhachitis with curvature of the leg. Also if the tibia and fibula are of unequal length, as, for example, after partial resection or necrotomy, or with excessive long- growth of the tibia or deficient growth of the fibula, seen most frequently after acute osteomyelitis. Further it may be due to ankylosis following inflammations of the joints or cicatricial contraction in the calf or sole of the foot. Other forms have been classified as "myogenic." In these the position of the foot is due to contraction of the muscles (contracture by habit), for example, to prevent pressure upon a painful affection in the sole of the foot or tension upon painful spots of inflammation near the ankle-joint or in the calf, or to compensate shortening of the limb. The foot is chiefly in the equinus position in these cases. Among the habitual contractures may be classified the cases of talipes varus due to long im- mobilization of the foot in a faulty position or to protracted recumbence. The talipes varus due to a primary myopathy — e. g., injuries of the mus- cles of the calf, myositis fibrosa, syphilitic induration of the calf muscles and ischemic paralysis of the muscles — is the result of cicatricial con- traction. The deformities which follow division of the dorsal flexors or occur in connection with pseudohypertrophy of the muscles are more closely allied to the large group of talipes due to neurotrophic disturb- ances of the muscles of the leg. Under neuropathic talipes varus are classified the intermittent spastic contractures, which may gradually become permanent deformities. They are found most frequently with cerebral and spinal paralysis, dis- eases of the spine and brain accompanied by muscular spasm and increased reflex irritability, in hysteria, and in certain poisonings, such as lead- poisoning and ergotism. Spastic talipes varus is rare compared to the paralytic form. Paralytic talipes varus is the most frequent of all the acquired forms. The foot is extended, inverted, and adducted by its own weight, and is then fixed in this position by the shrinkage of the muscles, tendons, liga- ments, and capsules. The effect of gravity upon the foot is shown in v. Volkmann's cases in which the calf muscles were paralyzed; the peronei and dorsal flexors still reacted, although weakly; nevertheless a talipes equinovarus developed, because the growth of the leg was retarded, and the child, therefore, had to let the foot drop in order to touch the ground 806 DISEASES OF THE ANKLE AND FOOT. with the toes. The talipes varus was accordingly not only paralytic, but also compensatory. It was stated above that if only the dorsal flexors and evertors were paralyzed and the action of the sound muscles and of gravity was therefore in the same direction, the varus position devel- oped and became fixed more rapidly and reached a higher grade. The fact that the paralysis is not infrequently limited to the dorsal flexors or evertors, together with the great influence of gravity, is responsible for talipes equinovarus being by far the most frequent form of paralytic contractures of the foot. It was also stated above that the varus position could be prevented by the everting action of bearing the weight on the foot when planted flatly. This seldom happens, however, because in walking the limp foot is very apt to strike the ground with its outer border, and because in most of the cases an equinovarus contracture already exists before the patient begins to walk. Both of these factors are naturally active to an even greater degree in the cases of paralysis limited to the dorsal Fig. .504. Skeleton of talipes varus. (Ch. Nelaton.) flexors and evertors. Furthermore, every attempt to walk causes the foot to be drawn into the contracture position by the active contraction of the muscles. Hence, in cases of partial paralysis use of the foot is almost never effectually corrective, so that contracture is the constant result. The varus contracture once established is increased rapidly bv weighting the foot. The causes of paralysis producing paralytic talipes varus are so extremely numerous that they cannot Vie mentioned here; they may be peripheral, but are much more often of central nervous origin. Acute infantile anterior poliomyelitis is by far the most frequent cause. From the above it follows that talipes varus can develop at almost any period from the formation of the primitive trace to advanced age, and from the most diverse causes. Any theory attempting to refer all the various forms of talipes varus to a common cause, therefore, seems impossible. Accordingly, the author cannot entirely approve of J. Wolff's effort to find among all the manifold causes, the remote CONTRACTURES AND DEFORMITIES OF THE FOOT. 807 causes, « » t" talipes varus, a common etiological factor, an immediate cause, which is supposed to consist of an inward rotation of the foot or entire limb, and a hindrance to outward rotation. Pathological Anatomy. — The most important changes occur in the skeleton, namely, in the shape and relation of the hones and in their joints. (Fig. 504.) The changes are so manifold, according to the etiology, in the varieties and subvarieties of talipes varus, that only those in the congenital form will he described and the several deviations from these, occurring in the acquired forms, merely mentioned. The anat- omy of primary idiopathic talipes varus has been little studied; there is no conclusive evidence thus far that it differs from that of the second- ary form, the few points of difference given by Bessel-Hagen being found in only a limited number of cases. It is also questionable whether these points are confined to primary talipes varus. Fig. 505. A Astragalus in newborn and in congenital talipes varus. (William Adams.) A, 1,2, 3. Normal astragalus seen from above and from under and outer side. B, 1,2, 3. Astragalus in newborn, with congenital talipes equinovarus, seen from same points. In a pronounced case of talipes varus the forepart of the foot is markedly adducted and inverted; the tip of the foot is extended and points inward; the sole faces inward; when placed upon the ground the foot rests upon its outer border or even upon the dorsum. As the most important changes take place in the tarsal joints we find the astragalus and calcaneum most altered. The astragalus is flattened and converges more than usual backward. (Fig. 505.) The trochlea articulates w r ith the tibia only by its posterior portion; in front the cartilage is atrophied. Kocher found the normal extension angle of 130 degrees between the tibia and astragalus increased to 150 degrees. The neck is lengthened on the outer side and twisted inward (Adams, Hiiter) (Fig. 506), forming an angle with the sagittal axis of the body of the bone of 50 to 64 degrees, instead of the normal 11 degrees in adults and 38 degrees in the newborn. (Parker, Shattock.) To this is due the inflexion of the foot in Chopart's joint. The scaphoid and cuboid are subluxated inw^ard. The anterior process of the calca- 808 DISEASES OF THE ANKLE AND FOOT. neum is thicker vertically (Hiiter); this prevents full eversion of the foot. The sustentaculum is depressed or absent. The calcaneum is extended more than the astragalus; it is also adducted; its posterior portion may articulate with the tibia and fibula. Normally the long axis of the calcaneum forms an angle opening forward with the astragalus; in congenital talipes varus the long axis, aside from its oblique direction downward, runs forward and inward. (Figs. 507 to 509.) The tuberosity is thus shifted outward toward the external malleolus, and the anterior process is turned inward. The Fig. 506. f 9 Obliquity of the neck of the astragalus, a. Normal astragalus in adult. A sagittal line through the middle of the trochlea forms an angle of 12 degrees with a line along the outer border of the neck. This angle, b, in a normal full-grown foetus = 35 degrees; c, in a full-grown chim- panzee, = 27 degrees; d, in a young full-grown orang-outang, = 45 degrees; e, in a child of eighteen months, with talipes varus, = 56 degrees; /, in a seven months' fcetus, with talipes varus, = 64 degrees; g, in a four to five months' fcetus, with talipes varus, = 44 degrees; ft, in a seven months' fcetus, in which the angle is strikingly small, = 31 degrees. (Parker and Shattock.) calcaneum, as a whole, is displaced outward, somewhat, so that the calcaneofibular ligament (middle fasciculus of external lateral ligament) is greatly shortened and the external malleolus is retarded in growth. The long axis of the calcaneum may be curved so that the bone is convex outward. (Kocher.) From this curvature and the rotation of the axis described by Bessel-Hagen it can be understood how the articulation for the cuboid becomes shifted entirely to the inner surface. The calcaneo-astragaloid joint is correspondingly altered. The CONTRACTURES AND DEFORMITIES OF THE FOOT. 809 surface on the calcaneum is directed more inward, the long diameter downward and inward; it is also convex from before backward, and divided by slight crista' into three parts. The highest and most external of the surfaces corresponds to the articulation for the external malleolus and the tibia, the middle surface, which goes to form the convexity largely, corresponds in its anterior portion to the articulation for the astragalus, and in its posterior to that for the tibia; the inner surface, which represents the completely atrophied apophysis of the calcaneum, corresponds to the lower and inner portions of the facets of the astragalus. These conditions are pronounced in direct relation to the age of the case. The changes in the smaller tarsals and metatarsals are unimportant. Fig. 507. Fig. 508. Fig. 509. Smi I \c Fig. 507. — Normal foot. Fig. 508. — Idiopathic congenital talipes varus in newborn. Fig. 509. — Same in adult, a b. Long axis of body of astragalus. C d. Long axis of os calcis. TV. Trochlea of astragalus. *'. m. i. Surface for internal malleolus. S. m. e. Surface for external malleolus. P. a. c. Anterior process of os calcis. 6'. t. Sustentaculum tali. S. a. n. Articular surface of astragalus for scaphoid. S. a. tf. New articulation of os calcis with tibia and fibula. C. t. Head of the astragalus. The tibia and fibula may be rotated inward in their lower portion about the long axis of the leg so that the external malleolus faces forward and outward instead of outward and backward. (Eschricht, Adams, v. Volkmann, Kocher, and others.) The transverse axis of the foot thus runs from behind and the inner side forward and outward. As a rule, the fibula is underdeveloped and curved toward the tibia, so that the interosseous space is narrowed. There are instances in which the tibia and fibula were rotated outward. In talipes varus due to uterine pressure they may be curved, convex outward. Usually the subluxations are more pronounced than deformation of the bones; at the same time the insertions of the ligaments become shifted gradually, the joint-capsules shrink, and the periosteum pro- liferates at the points of insertion. The greatest amount of displace- 810 DISEASES OF THE AX RLE A XL) FOOT. ment occurs in the mediotarsal, tibiotarsal, and calcaneo-astragaloid joints. The astragalus is forced forward by excessive extension and inversion from between the malleoli and becomes adducted, so that during flexion of the foot the front of the tibia strikes against the trochlea and may form a groove in it. The malleoli become approxi- mated and together with the growth of periosteum on the front of the astragalus prevent reduction. The calcaneum becomes inverted, so that the tuberosity is separated farther from the tip of the external malleolus, in contrast to its approaching it in the congenital form. In contrast also to the congenital form the bones of the leg are usually rotated outward. The soft parts as a whole are shortened on the concave side and lengthened on the convex side of the foot. Shrinkage also takes place in the calf. The ligaments are shortened most in the region between the internal malleolus, calcaneum, astragalus, scaphoid, and first cunei- form. The capsule of the ankle-joint is shrunken behind, and in front it is either stretched by the extended position of the anterior border of the trochlea of the astragalus, or is inserted on the astragalus close to the anterior margin of the tibia, and thus stretched tightly across the cleft of the joint. In the latter case the insertion is displaced, a condition which Bessel-Hagen regarded as characteristic of the primary talipes varus. Of the muscular shortening, that of the gastrocnemii is most im- portant; the tibialis anticus and posticus and short plantars are also shortened. Of the shortening of the soft parts in the sole, that of the skin and plantar fascia has the greatest significance. The tendons in the foot are often shifted in proportion to the degree of the deformity. The groove for the peronei is shifted to the outer and under surface of the anterior process of the calcaneum instead of being on the under surface of the cuboid. The tendon of the tibialis posticus runs along a smooth groove on the posterior surface of the tibia to the posterior margin of the internal malleolus. The dorsal flexors are mostly displaced inward and with them the fundiform ligament is drawn inward and lengthened. In some instances the ligament is inserted on the outer or dorsal side of the neck of the astrag- alus or on the same side of the scaphoid, instead of in the sinus tarsi. Bessel-Hagen regards this anomalous insertion as peculiar to idiopathic talipes varus; in these cases he also found the origins of the short foot muscles shifted and abnormal ligaments at the joints. In other respects the muscles are unchanged, as a rule, in congenital non-paralytic talipes varus. Very rarely one finds a slight amount of intrauterine atrophy, which is referable to lack of movement of the foetal foot. As long as the foot is not used to stand or walk no essential changes occur, but the first attempts to walk increase the deformity if the foot is inverted farther, and not everted, by the body-weight. The more the dorsum becomes the supporting point of the foot, the greater becomes the extension and inversion and the inflexion in ( nopart's joint. This leads to subluxations, to further deformation, and the formation of CONTRACTURES AND DEFORMITIES OF THE FOOT. 811 new joints. The astragalus may be dislocated from between the malleoli. The posterior part of the trochlea, still in contact with the malleoli, may be reduced in length to a few millimetres, become flattened and atrophic, while the anterior part, carried with disintegrating cartilage, becomes irregularly thickened, and thus may prevent reduction. The capsule may become adherent to the cartilaginous surface in front. Knpprecht has called attention to the changes in the body of the astrag- alus; in talipes varus it represents a wedge driven in between the arch of the foot and the leg from in front and the outer side. The frontal section is no longer a quadrate, as in a normal foot, but a trapezoid, in very pronounced cases a triangle with apex at the inner side. The neck becomes more and more curved downward and inward, the scaphoid becomes increasingly subluxated and the articular surface of the caput tali more distinctly divided into two parts. The calcanenm is increasingly extended and inverted; often the upper surface comes to articulate with the posterior edge of the tibia and fibula. The tuber- osity remains in close proximity to the external malleolus. The calca- neum appears longer and lower, although the anterior process is rela- tively high. The cuboid gradually becomes subluxated inward. The abnormal relation of the other bones and joints of the tarsus and meta- tarsus becomes more marked, and in consequence the arching and inflexion of the sole at the inner border more pronounced, eventually even to an acute angle. The muscles of the foot and leg, in fact to a certain extent of the entire extremity, atrophy, but, as a rule, without apparent changes in the nerves. Even after correction the atrophy of the calf-muscles persists, a fact explained by the changed function of the gastrocnemii, which does not return to normal after correction. The changes in the bones extend throughout the entire extremity and to the pelvis and spinal column, as shown especially by H. v. Meyer. The line of gravity of the body is thrown far back in talipes varus because of the lack of support normally given by the metatarsals; the patient walks, therefore, with the body curved backward. This curvature is increased by inclination of the pelvis and consequent lordosis. The gait is inelastic. The lateral equilibrium is facilitated by rotating the legs inward; as the result the posterior and outer part of the articular surface of the head of the femur degenerates, the pelvis becomes more inclined and, as the pressure of the femur acts more in the direction of the sacrum, it gradually becomes narrowed laterally. This sequence given by v. Meyer does not always take place, as one occasionally finds the leg rotated abnormally outward. In acquired talipes varus the pathologico-anatomical changes vary at the outset, obviously, according to the etiology. These differences become somewhat less marked after the foot has been used for any length of time, so that the changes may resemble those in old cases of congenital origin. As a rule, at the outset the foot is merely fixed in the positions possible physiologically, but gradually these positions are exaggerated and are followed by subluxations and changes in the 812 DISEASES OF THE ANKLE AND FOOT. bones. The latter develop chiefly in the cases occurring in childhood, less rapidly in those acquired later in life. The astragalus, for example, may undergo deformation similar to that in congenital talipes varus, but usually the deviation of the neck is not so marked. For this reason the inflexion in the line of ( nopart's joint, which occurs so frequently in the congenital forms, is absent, as a rule, in the acquired cases. Symptoms and Diagnosis. — The clinical picture of talipes varus may be constructed from the pathological anatomy. In the congenital form, as seen in children, the foot is inverted and adducted, in severe cases till at an acute angle to the leg. The sole of the foot faces inward or even backward, the inner border upward, the outer downward. The foot appears shortened, because it is bent upon itself. This inflexion at about the scaphoid maybe very sharp. The tip of the foot is depressed, the heel elevated and often narrow and short, so that the tuberosity can hardly be felt. The latter lies nearer the external malleolus, which in turn projects prominently and often lies farther back than normally. The internal malleolus is less prominent than normally. The dorsum of the foot is unduly arched and irregular, owing to the projection of the head of the astragalus and the anterior process of the calcaneum. If the patient walks, the deformity is increased until the weight is supported on the outer border or even the dorsum of the foot. The tuberosity of the fifth metatarsal, or the cuboid and the anterior process of the calcaneum, or even the neck and trochlea of the astragalus, form the point of support. In the latter case the dorsum faces forward and downward, and the sole backward and upward. A deep fold divides the anterior from the posterior portion of the foot at the level of the mediotarsal joint. The foot is bent together, the heel small and atrophic. Thick callosities grow on the dorsum at the point of support, and under- neath the skin bursa? develop which may become inflamed and painful, and even suppurate. They often leave fistulas. The muscles of the leg atrophy, so that the leg and deformed foot look like a stilt. The appearance of acquired talipes varus is very similar, varying according to the degree of the curvature. In the paralytic form the coolness and bluish color of the skin, the atrophy of the muscles, and if acquired in childhood, the shortening of the limb, are very striking. The plantar flexion of the foot and toes is more marked even in mild cases. On the other hand, the inflexion at the mediotarsal joint, the changes in the tarsus, and the proximity of the tuberosity of the calca- neum to the external malleolus are less pronounced than in the con- genital form. These dissimilarities and the history make the differential diagnosis of the paralytic from the congenital form easy. Treatment. — The treatment of congenital talipes varus should be instituted soon after birth if the child is healthy, in order to take advan- tage of the rapid growth of the bones during the first few months, other- wise the deformity increases proportionately. The shortness of the foot often makes early treatment difficult; nevertheless it is preferable, especially if the deformity is marked. In almost all cases corrective CONTRACTURES AND DEFORMITIES OF THE FOOT. 813 manipulation and massage can be begun immediately after birth. The results are often surprising. As the manipulation should be carried out several times daily, the persons caring for the child should be taught how to conduct it. Frequent co-operation is advisable on the part of the surgeon, ;is the laity do not usually make the treatment energetic enough. The lee is held in one hand while the foot is everted and abducted with the other; or if the inflexion of the tarsus is marked, the ankle and heel are held in one hand while the front of the foot is flexed with the other. If the foot is extended, it should be flexed as much as possible. This order, eversion and abduction, and then flexion, should be followed out in every manipulation. In the intervals the foot can be held interruptedly or continuously to great advantage in the corrected position by means of a bandage. Adhesive-plaster strips hold the foot more firmly, but are not so easily changed and are apt to irritate the skin. Fig. 510. Fig. 511. Fig. 512. Konig's felt-splint. (Hoffa.) Various splints are in use. Adams fastens a straight splint along the outer side of the leg, so that it extends beyond the foot, and bandages the latter to it. Splints made of pliable felt are better. (P. Brims, Vogt, Konig.) A form is cut out of felt, softened by heating, and bandaged to the corrected foot till it hardens; it is then taken off and shaped; the foot is bandaged w T ith gauze and the splint then bound in place. (Figs. 510, 511, and 512.) Any material which is pliable and hardens, such as rubber, pliable papier-mache, or tin, etc. , may be used. The simple appa- ratus of Kolliker, Taylor, Beely, and others act similarly, and in addition have the advantage of making elastic traction. Beely's splint (Fig. 513) consists of three curved plates padded with felt and connected by flexible iron strips adjustable by means of screws. The flexed position of the knee is important to insure continuous eversion and flexion of the foot. Kolliker's splint (Fig. 514), an iron strip with a thick felt pad, is made after a rubber model shaped to the foot and leg while warm and pliable; it runs over the dorsum of the foot, under the sole and along the outer side of the leg to above the knee. These splints have the advantage of 814 DISEASES OF THE ANKLE AND FOOT. being removable so as to allow manipulation, baths, massage, etc., but have the disadvantage of being hard to apply accurately and of pro- ducing decubitus; hence they are of less value in clinical work than permanent splints. The same applies even more to the numerous club-foot apparatus, 1 various types of which are represented by the apparatus of Scarpa (Fig. 515) and Meusel (Fig. 516). The simplest form of Scarpa's splint consists of a laced shoe, to which an outer strip is attached on the sole. This strip is hinged at the level of the ankle-joint to a long outer strip fastened below the knee by a strap; the apparatus makes elastic traction outward on the foot, and thus everts it. The apparatus of Venel, Stro- meyer, Little, Tamplin, Adams, Reeves, Stillmann, and many others are constructed very much on the same principle. Numerous appliances Fig. 513. Fig. 514. Beely's splint. (Hoffa.) Kolliker's splint. (Hoffa.) were constructed to overcome the adduction of the foot, for example, by means of spring strips, elastic bands, cog wheels, etc., fitted to shoes, the front part of which could be rotated outward. The same methods were used to overcome the extension. Apparatus were also made with screw appliances, adjustable ball and socket and hinge joints, cog wheels, etc., and used partly for forcible correction. All of these apparatus with complicated mechanism are little used at present. Elastic traction is employed more frequently; Barwell, Sayre, Andrews, Willard, Prince, and Sprengel have suggested simple dressings by which it can be applied. Although in some of these the elastic bands are 1 The details of the apparatus and the bibliography are given in the text-books of orthopaedic surgery of Schreiber, Redard, Hoffa, and others. CONTRACTURES AND DEFORMITIES OF THE FOOT. 815 attached to the foot and leg by means of adhesive plaster, they are more commonly attached to a shoe with side strips fastened to the leg. (Hiiter, Liicke, Sayre, Willard, Stillmann, Beely, etc.) Holla recommends Hessing's sheath apparatus with elastic bands. Tin's makes an excellent splint, Imt is expensive. Other methods of fastening straps, strips, etc., to the foot to increase the lever action of the elastic traction are complicated and uncomfortable. A simple method of utilizing the action of body-weight in mild cases, or for after-treatment, is to drive staples (> — ' shaped) into the outer side of the heel and of the sole at the ball of the foot, so that they project three-quarters to one inch and evert the foot in walking; the shoe should be a snugly fitting, high-laced boot (Biigelschuh of Roser). Older patients can be taught to use mechanical apparatus for exercise and correction. Fig. 515. Fig. 516. Scarpa's splint. Meusel's apparatus to rotate the foot outward. It is very important to overcome the inward rotation at the knee-joint and hip-joint. It often persists after correction of the club-foot and increases the danger of recurrence, whereas outward rotation hinders adduction of the foot. Apparatus may be necessary to prevent inward rotation. In the recumbent patients the limb is easily rotated outward and held by a T-splint, etc. In ambulant patients it is more difficult; sometimes an iron side splint fastened to a pelvic brace is sufficient; Charriere shifted the attachment farther back on the pelvic brace; Liicke and Bruns applied an apparatus extending down to the knee and rotated it outward bv means of an elastic band running backward from the outer side strip to the pelvic brace or a belt; Bonnet controlled 816 DISEASES OF THE ANKLE AND FOOT. the rotation by a screw at the pelvic brace; in Meusel's apparatus (Fig. 516) the leg brace is rotated and fixed on the lateral thigh strip at the knee; in Sayre's brace the thigh strip is rotated by means of a screw-key; Beely's scheme of an elastic band fastened to the outer thigh strips on each side and passing across the pelvic brace behind is simple and effectual; Heusner used spiral splints made of flat spring metal and of three grades of torsion strength, beginning with the weakest, applying it only at night, and discontinuing the same as the resistance diminished; the splints were fastened to the shoe by a catch. The continuous fixation splints are unquestionably the simplest, require the least supervision, and are, therefore, most widely used in clinical practice. Of these the permanent plaster-splint, formerly used for gradual correction of the deformity, is now employed chiefly to maintain the position after manual correction. While the knee is held by an assistant, the foot is everted and flexed as far as possible and held in this position by hand or by means of a traction bandage around Fig. 517. - Oettingen's method, (v. Bergmann.) the mid-foot pulled upward and outward. The latter makes it more difficult to apply the dressing to the forefoot. The splint should be applied with little or no padding, extending from the base of the toes to above the knee, with the latter flexed slightly to insure outward rotation of the foot. While the splint is soft it is advisable to increase the eversion and flexion by laying the hand flat against the sole and pressing upward and outward until the plaster hardens or by placing the foot upon the ground with the knee flexed and pressing the leg directly downward and outward. Anaesthesia facilitates the process greatly, but is not indispensable unless forcible correction is necessary. Numerous appliances are suggested to hold the foot while putting on the plaster, but are superfluous. The plaster splint is left on for from three to six weeks unless further correction is necessary, in which case it is removed in about two weeks and renewed after increasing the eversion and flexion. In older children it is better to have them use the foot; to strengthen the splint for this purpose it may be reinforced with starch bandages, or, better, with bandages saturated with a mixture of magnesium carbonate and sodium CONTRACTURES AND DEFORMITIES OF THE FOOT. 817 silicate or a solution of celluloid and acetone. This makes a strong and impervious dressing. The method proposed by Oettingen, and in use for some time in v. Bergmann's clinic, is simple and especially useful in cases of talipes varus in the newborn and young children. (Fig. 517.) After the foot has been corrected by manipulation, it is painted with Fink and Heus- ner's adhesive mixture (terebinth, venet. 15, mastich 12, resin 28, resin, alb. 8, alcohol (90 per cent.) 180, ether 25). A twilled bandage is then applied beginning at the outer border of the foot, passing over the dorsum to the inner border and then under the sole; it becomes firmly adherent in a few seconds. The lower third of the thigh is then painted; the foot is then abducted and everted, and the bandage drawn tightly over the flexed knee and passed around and behind the calf, then downward over the front of the foot to the inner side, and under- neath the foot to the outer border. Three turns may be made in this maimer. The first dressing is left on two days and the later ones for two or three weeks. The last dressing is replaced by an elastic bandage, It to 2 inches wide, with buckles, applied in the same manner and worn at night. When the child begins to walk a shoe is worn which is raised f to f- inch on the outer side. The older method of gradual correction in plaster-splints demands much time and patience, and is seldom able to be carried to the end. So it has been very generally abandoned. Konig's plan of forcible cor- rection is used instead as a rule and retention splints only applied to maintain the accomplished result. A method somewhat intermediate between these two procedures is that of J. Wolff; he applies a splint with a cut on the inner side and a wedge removed on the outer side, so that the foot can be moved and gradually corrected in the splint about every three days. The foot is bandaged in the position attained after each correction. When the correction is complete the splint is smoothed off and strengthened with strips of wood and silicate. The patient then wears a shoe over the splint for six to nine months. The principle of the method is the same as that of the adjustable apparatus, but the splint fits better and facilitates more rapid correction. Wolff lays the greatest stress upon correcting the adduction and allowing active use of the foot to do the rest. If the manipulation is carried out with the splint on, the latter is more apt to become wrinkled and produce decubitus than if the manipulation were done previously. (Konig's method.) Konig was the first to use this method, for the application of which valuable suggestions have been made recently by Lorenz. It can be recommended for all cases up to the twentieth year. Konig's Method. Konig first divided the tendo Achillis, and if necessary the plantar aponeurosis, subcutaneously. The author thinks it is better to divide the tendon after the foot has been corrected. In young children division of the aponeurosis is unnecessary; in older people it is often advantageous. With the patient under anaesthesia and in the lateral position the first step is to correct the adduction of the front part of the foot. The dorsum of the foot is placed upon a Vol. III.— 52 818 DISEASES OF THE ANKLE AND FOOT. padded prism-shaped wooden block, the inner side of the heel grasped with one hand, the front of the foot with the other, and with increasing Fig.. 518. m ■■ Lorenz' method of manual correction. Correction of varus deformity. Fig. 519. Lorenz' method of manual correction. Flattening the sole. force, and if necessary with interrupted pressure, the foot is gradually straightened. (Fig. 518.) According to Konig cracking sounds should CONTRACTURES AND DEFORMITIES OF THE FOOT. 819 be expected as the ligaments are torn and the hones are broken; but with Lorenz the author prefers to proceed slowly, especially in the case of young children, in whom pressure by jerks is ineffectual on account of the elasticity of the foot. In older cases, which cannot be straightened by gradual pressure, the ligaments can be torn and the bones broken by jerking. The skin should be drawn together on the inner side of the foot previously to prevent its being torn. In the ease of children the block may not be necessary, but it is important to grasp the heel and ankle firmly with one hand to prevent fracture of the malleoli. The second step is to overcorrect the inflexion of the foot, namely, the cavus deformity, until the sole is convex. For this the counter- Fig. 520. Lorenz' method of manual correction. Correcting the equinus deformity. traction of the tendo Achillis is important, hence the mistake of dividing the tendon previously. The fibula is liable to break if the front of the foot is jerked or flexed too forcibly. The correction is facilitated by using Lorenz' traction sling. (Fig. 519.) The third step is to overcome the equinus position of the foot as a whole. One should not be deceived by the cushion of fat on the heel, but ascertain the position of the calcaneum by its tuberosity. Generally it is necessary to divide the tendo Achillis; even then the correction is often difficult. Direct manip- ulation of the heel is often required in addition to forced flexion of the tarsus if the foot is small and elastic. (Fig. 520.) Finally, with the malleoli well fixed, the foot should be everted by rotary movements and 820 DISEASES OF THE ANKLE AND FOOT. pressure made on the outer border of the calcaneum to overcome the valgus position of the posterior tarsals. If the foot is properly corrected, it should be easily brought into a pes calcaneovalgus position, as, for example, by pulling upon the little toe. Although the correction may be accomplished with patience and per- severance in one sitting, it is better to do it by degrees at intervals of two to three weeks. As a rule the author corrects the adduction and inflexion of the foot the first time, and the equinus position later after dividing the tendo Achillis. As manipulation is ineffectual in older patients, various apparatus have been suggested, the more complicated of which have been aban- doned in Germany for the simpler ones, such as the widely recommended modelleur-osteoclast of Lorenz. (Fig. 521.) Fig. 521. Lorenz' modelleur-osteoclast. With Lorenz' apparatus the individual components of the deformity can be overcome by gradual traction and in severe old cases corrected under anaesthesia. Here again we prefer gradual correction in several sittings. Stille, the instrument-maker in Stockholm, has recently made improvements in the Lorenz apparatus. Considerable swelling is to be expected if much force has been used in the manipulation, so that the retention splint should not be applied too tightly. The foot should always be padded. If only moderate force was used, a plaster-splint can be applied at once, and the foot elevated and kept under observation for the first few days. If the toes swell, the splint can be cut slightly on the dorsum and the edges bent up. After CONTRACTURES AND DEFORMITIES OF THE FOOT. 821 the swelling has subsided the retention splint is replaced by a permanent one to be worn for several months; later massage and active motion to exercise the muscles and mobilize the joint; or, a removable splint may be applied and massage begun earlier. Complete division of the various tendons and ligaments has been sug- gested by a few authors to facilitate correction. The tendon of the tibialis posticus is the one most frequently divided. The author divides the tendo Aehillis and plantar fascia if necessary, but never any other tendons or fascia. Division of the tendo Aehillis — possibly also the plantar fascia — is generally necessary to complete the last step. Unless the tendon lies close to the bone, subcutaneous tenotomy is preferable to open division. As it is better not to divide the deep fascia in the sole, the aponeurosis can also be divided subcutaneously. Phelps recommends open division of all the contracted tissues in the sole. This method gives good results and has met with wide approval, but we believe that the cases rectifiable by Phelps' operation can be corrected by manipulation followed by apparatus. The method is preferable to resec- tion in some cases, but cannot replace it entirely. The same long after- treatment as after manual correction is required to prevent recurrence. Subcutaneous Division of the Tendo Achillis. — The tendo Aehillis can be divided subcutaneously h to 1 inch above its insertion; with the child anesthetized, the knee extended and held by an assistant and the foot flexed, a lance-shaped or slightly curved tenotome is inserted on the inner side, in front of and parallel to the tendon with the cutting edge facing the foot, until the point is felt on the outer side under the skin; the blade is then turned, and with the thumb upon the skin behind the tendon the latter is divided until it gives suddenly and a distinct gap can be felt between the stumps. Some surgeons prefer to divide it from behind forward from the inner side, but unless care is used the posterior tibial artery can be injured. The bleeding is slight; a small aseptic dressing is applied with pressure after correction. Of the various operations on the bones necessary in extreme cases, the following table made by Lorenz in 1885 needs essentially no additions: A. Osteotomy. 1. Linear division of the scaphoid through the sole. (Hahn.) 2. Linear osteotomy of the tibia and fibula above the joint. (Hahn, Vincent.) B. Enucleation. 1. Of the cuboid. 2. Of the astragalus (Lund, Mason): (a) with resection of the tip of the external malleolus (Mason, Ried); (b) with removal of the spongiosa of the astragalus, leaving its articular surfaces (Yerebely); (c) with excision of a vertical wedge with base outward from entire thickness of the front of the calcaneum. (Hahn.) 3. Of the astragalus and cuboid. (Albert, Hahn.) 4. Of the astragalus, cuboid, and scaphoid. (West.) 5. Of the scaphoid and cuboid. (Bennet.) 822 DISEASES OF THE ASKLE AND FOOT. C. Resection. 1. Of the head of the astragalus. (Lticke, Albert. I 2. Of a wedge from the outer half of the neck of the astragalus. (Hiiter.) 3. Of wedges with base outward and at right angles to each other from the mediotarsal and calcaneo-astragaloid joints. (Rydygier.) 4. Of a wedge from the entire tarsus. (O. Weber, Da vies and ("oiler, R. Daw. Excision of the astragalus and resection of a wedge from the tarsus "ill are the operations used chiefly at the present time. As both are some- what deforming they should never be used in young children and only in the very severe old cases in older people. Excision of the Astragalus. — Slightly curved incision from the external malleolus over the prominence of the astragalus to the outer side of the extensor tendons. After lifting off the tendons of the peronei, Fig. Fig. 523. Congenital club-foot after astragalectomy and cuneiform tarsal resection, same as Plate XXI. (Hartley.) which are often displaced forward, the talofibular ligaments (and in con- genital talipes varus the calcaneofibular) are divided, the head of the astragalus is seized with bone-forceps, and the astragalus extracted after dividing the ligaments in the sinus tarsi and the deltoid ligament. The various joints are then mobilized and the adhesions broken up X X < Ph h CONTRACTURES AND DEFORMITIES OF THE FOOT. 823 forcibly, if necessary by dividing the tendo Achillis and the plantar aponeurosis. Resection of a wedge from the anterior portion of the calcaneum may be required. Division of the connections between the fibula and calcaneum is essential in order to correct the position of the calcaneum. Complete resection of the external malleolus is not advisable; it may be rounded off to prevent pressure against the skin. Resection of a Wedge prom the Tarsus. — A transverse incision is made from the tuberosity of the scaphoid passing over the most prominent point on the dorsum to the outer border of the foot. In the case of paralytic talipes varus two incisions parallel to the extensor tendons are advisable on account of the poor nutrition of the skin. The fascia is divided, the extensor tendons and the peronei lifted off with the elevator, and the mediotarsal joint exposed. The wedge — with base on the outer side comprising the anterior portion of the calcaneum and part of the astragalus and cuboid, and with apex situated in the inner part of the scaphoid, or at the inner surface — is cut out with the chisel, or with a bone-knife if the bones are soft. If necessary to facilitate correction, the tendon of the tibialis posticus maybe divided. Excision of a second wedge may be required to overcome the inversion of the calcaneum. In either operation the correction must be complete to prevent recur- rence. Later, orthopaedic treatment continued for some time and the wearing of a shoe with a side brace are desirable, although not indis- pensable if the operation is effectual. Comparing the two operations it should be noted that cuneiform osteotomy shortens the foot con- siderably and makes almost all the tarsal joints stiff. By excision of the astragalus the foot is shortened and the malleoli lowered. A fairly movable joint may form between the calcaneum and tibia. Sometimes osteotomy or cuneiform resection are required in addition. As a rule compensatory mobilization takes place in the tarsometatarsal joints after both operations. A choice between the two operations depends chiefly upon whether the deformity involves principally the region of Chopart's joint or the astragalus and calcaneum, as otherwise the functional results are equally good. Pirogoff's amputation is sometimes advisable in old severe cases in older people, especially when accompanied by suppuration of the accessory bursas, pressure sores and suppuration of the joints. In general, acquired talipes varus is more easily corrected than the congenital form, unless it is very old and associated with deformation of the bones. The prognosis of congenital talipes varus depends upon the amount of deformation of the bones and joints, and becomes less favorable the earlier the alterations occurred in utero; the position and deformation of the calcaneum and astragalus are especially significant. In slight congenital cases the deformity can be overcome entirely; in the severed cases the limb can still be made useful. Recovery may be said to be complete if the foot can be everted actively (not considering the paralytic and post-operative ankylotic cases), and permanent if there is no recurrence within six months. Active mobility is dependent not 824 DISEASES OF THE ANKLE AND FOOT. only upon restoring the shape of the foot, the bones and joints, but also the function of the muscles, especially the evertors. Recurrence means that treatment was discontinued too soon; the patients usually know less about the action of the apparatus than about the function of the foot, so that the advisability of discharging the patient in an apparatus before the full function of the foot is restored is questionable. As a rule, particularly among the poorer classes, the apparatus is neglected or very badly repaired. In such cases the recurrence dates from the application of the apparatus. If recurrence takes place, constant wearing of an apparatus, tendon transplantation, or arthrodesis are inevitable. In paralytic club-foot the above treatment can only correct the de- formity; apparatus must be worn continuously to maintain the correction. Tendon transplantation is to be considered chiefly for paralysis of part of or all the evertors. If only the peronei are paralyzed, the outer half of the tendo Achillis can be split up to the muscle and sutured to the distal stumps of the peroneal tendons. If the extensor communis digi- torum is paralyzed, the extensor hallucis or part of the tibialis anticus can be sutured to the distal stump of the divided extensor communis. The two procedures may be combined. Lange's periosteal tendon transplantation is also very useful; in v. Bergmann's clinic we have split the tibialis anticus, drawn the outer half down beneath the skin and sutured it to the periosteum of the cuboid with good result. The numerous varieties of transplantation which are practical and have been applied successfully are given in the literature. (Drobnik, Vulpius, and others.) Arthrodesis, although capable of giving permanent results with the foot in a good position, is nevertheless being more and more relin- quished in favor of tendon transplantation, so that it may be said that it is indicated only in the cases of paralysis too severe to be benefited by tendon transplantation. It is usually sufficient to stiffen the ankle- joint, although occasionally Chopart's joint or the calcaneo-astragaloid joint has to be ankylosed also. The best incision is an anterior trans- verse or curved incision, through which the tibiotarsal and mediotarsal joints are both accessible. Talipes Equinus. — The term talipes equinus is applied to the deform- ity in which the foot is fixed in extension and cannot be flexed to a right angle. Strictly speaking the contracture therefore affects only the tibio- tarsal joint, in which flexion and extension take place, although the other joints of the foot are concerned in severe cases. Pure talipes equinus is rarely congenital, as external forces acting upon the extended foot in utero usually produce a talipes equinovarus. Acquired talipes equinus, although a rather common deformity, is less frequent than congenital talipes varus; its etiology is very similar to that of the latter. Paralysis is the most common cause. The contracture develops most rapidly if only the dorsal flexors are paralyzed; but even if all the muscles are paralyzed, the foot drops by its own weight unless pre- vented by being used in walking. As the foot usually also becomes CONTRACTURES AND DEFORMITIES OF THE Fool'. 825 bent in the mediotarsal and tarsometatarsal joints, it is likewise adducted and inverted (talipes equinovarus). Talipes equinovalgus (pes valgo-equinus; tains pied erenx, valgus de I'avantpied, Duch- enne) is rare, and occurs occasionally after paralysis of the tibialis anticus alone. The extensor digitonun cannot by itself prevent the equinus position, but as it is stronger than the extensor hallucis it abducts and everts the front part of the foot. The foot is everted still more by the peronei if the extensors are paralyzed. The position of the toes varies. If the tibialis anticus alone is paralyzed, the toes are usually extended actively to flex the foot as much as possible and so assume a claw-posi- Fig. 524. Talipes cavo-equinus and claw- toe from paralysis of the tibialis anticus. (Duchenne.) Fig. 525. Different degrees of talipes equinus paralyticus. (Adams.) tion. (Fig. 524.) This is increased by walking on the ball of the foot. Even if the extensors of the toes are paralyzed, the toes may be forced into the same position by the weight being thrown on the ball of the foot. 326 DISEASES OF THE ANKLE AND FOOT. In extreme cases they may become subluxated. If, after paralysis of the extensors, a marked talipes equinus develops before the patient learns to walk, the toes may become flexed. The patient then walks upon the dorsal surface of the toes, or the dorsum of the foot, or even the trochlea of the astragalus. As a rule in these cases the foot is also more or less in the varus position. (Fig. 525.) In almost all cases of talipes equinus the arch of the foot is increased. If the foot is not used, this is due to the action of the antagonists and the weight of the front of the foot; and if used, it is due to the patient's effort to increase the equinus position, so that the foot can be used as a stilt without taxing the muscle of the calf unduly. If the equinus position is very marked, the arch is increased by the body-weight and the foot appears shortened. Neuropathic spastic talipes equinus occurs with spastic acampsia, hysteria, pressure myelitis, and cerebral paralyses. At first it may be intermittent, but usually becomes permanent in time. Of the various other pathological processes which likewise produce talipes equinus, in much the same way that they produce talipes varus, we should mention : cicatricial contraction of the skin of the calf, shrink- age of the calf muscles following purulent or non-purulent inflamma- tions, fractures of the malleoli and in the tibiotarsal joint uniting with deformity, non-traumatic deformities of the bones, such as hyperostoses, etc., ankylosis following inflammation of the tibiotarsal joint. Talipes equinus, like talipes varus, is also frequently a contracture by habit. It is seen in bedridden, feeble patients; also as the result of faulty immobilization, or of walking on the toes for years to compensate short- ening of the limb, or to prevent the discomfort of some painful affection of the heel. Symptoms. — The limb is lengthened; to compensate this the knee is flexed and the pelvis elevated. The gait is stiff and somewhat of a hop- ping character. The leg is swung outward at each step in order to clear the ground with the front of the foot. This is most pronounced in the paralytic form. If the limb is shortened by atrophy, the gait is more limping than hopping. If the condition is bilateral, the patient generally has to use a cane or crutches. Usually the foot becomes fatigued easily. Walking for any length of time often produces pain in the tarsus and the metatarsophalangeal joints. Thick callosities usually form over the heads of the metatarsals and may be very painful. Pathological Anatomy. — In mild cases the skeletal changes are insig- nificant. The essential of the deformity is the extension of the astragalus and calcaneum, which is not in excess of the normal, but cannot be over- come on account of the shortening of the soft parts. In more severe cases subluxation may take place in the tibiotarsal joint, so that the astragalus articulates with the tibia and fibula only by the posterior part of the trochlea; on this portion the articular surface is lengthened and the bone is flattened. (Fig- 526.) The cartilage in front is more or less atrophic and occasionally replaced by abnormal thickening of the bone. The articular surface of the head projects into the dorsum CONTRACTS 11 US . 1 A I) DFFOR M I Tl ES OF THE FO O T. 827 .mid is worn off obliquely below. The scaphoid and cuboid arc sub- luxated toward the sole. The calcaneum is extended sharply with the astragalus and may articulate with the posterior border of the tibia or the external malleolus. The smaller tarsal bones are usually more wedge-shaped, like the stones of an arch. All these changes are modi- lied according as to whether the patient walks on the dorsum or the sole of the foot with the toes sharply extended; if on the sole, the toes are subluxated backward on the metatarsals. (Fig. 526.) The heads of the metatarsals then project forward and support the weight of the body. Fig. 526. Old talipes equinus. (v. Bruns.) The capsules and ligaments are stretched on the convex side and shortened on the concave side of the foot. Of the muscles, the gas- trocnemius is shortened the most, the others of the calf less so. The short plantar muscles are markedly retracted. Treatment. — The treatment of talipes equinus is very similar to that of talipes varus, namely: in mild cases, manipulation, massage, and exercises; in severe cases, division of the tendo Achillis, forcible cor- rection in several stages, and in the intervals immobilization. Numerous apparatus are used to effect gradual correction; in some the patient 828 DISEASES OF THE ANKLE AND FOOT. flexes the foot passively, as, for example, with Bonnet's apparatus. Many modern medico-mechanical apparatus are similar but more effectual. Elastic traction is easily applied by means of Heidenhain's contrivance, which consists of a strap and buckle passed above and below through two rubber rings, attached in turn below to a loop passing under a sole plate at the ball of the foot, and above to adhesive- plaster strips on the thigh. (Fig. 527.) The elastic traction can also be attached to a jointed plaster-splint. There are very many portable apparatus acting by means of elastic traction, examples of which are given in Figs. 528 and 529. Hessing's more expensive apparatus is to be recommended for those who can afford it. These portable apparatus are applicable in mild cases not Fig. 527. Fig. 528. Fig. 529. Heidenhain's traction loop for talipes equinus. Hudson's apparatus. Goldschmidt's apparatus. requiring previous correction, and for such are the most comfortable methods of treatment. They are especially useful for the paralytic cases which always require permanent support to prevent recurrence. Old cases in which the dislocated astragalus is too wide to be reduced, necessitate removal of the astragalus, or part of the same and of the malleoli. If the ankle-joint is ankvlosed, supramalleolar osteotomy or partial resection of the joint may be necessary. In mild cases walking is facilitated by supporting the heel. In paralytic cases, if the paralysis is limited, tendon transplantation is indicated, other- wise arthrodesis is preferable. Or if shortening of the limb exists at the same time, Wladimiroff and Mikulicz' resection has been performed instead of arthrodesis in order to lengthen the limb. (v. Bruns.) In the spastic cases division of the tendo Achillis or transplantation of the CONTRACTURES AM) DEFORMITIES OF THE FOOT. 829 plantar flexors into the dorsal flexors should be tried. In severe cases a talipes cavus is sometimes left after overcoming the extension; it requires treatment if it does not disappear of itself. (See Talipes Cavus.) Flat-foot iTalipes Valgus). —By flat-foot the author understands the deformity in which the foot is fixed in eversion and abduction. A congenita] and acquired form can he distinguished as in talipes varus. Etiology. — The statistics as to the frequency of congenital flat-foot vary within wide limits. HofTa estimates that only 4.3 per cent, of all eases are congenital. Kustner— to whom we are indebted for the most detailed description of the congenital form — found 15 Hat feet in 300 — that is, in 150 children, who had to be carried hut were otherwise healthy (5 per cent.). According to the prevalent idea, the foot in the newborn is almost always Hat. As noted by Hiiter, the arch does not develop till after birth. As the layer of subcutaneous fat is relatively thick in the sole of Fig. 530. Fig. 531. Congenital flat-foot. (Kustner.) the newborn and the bones and ligaments are extremely yielding, a decision as to the presence or absence of flat-foot cannot always be made, as emphasized by Kustner, from footprints or foot-tracings of charcoal upon glass. Therefore Kustner designated as flat-foot the cases giving the following symptom-complex: The sole is distinctly convex and the foot is accordingly longer; if the condition is unilateral, this lengthening can be verified/ The dorsum of the foot is concave; over it the skin is thrown into folds, whereas on the sole the normal folds are less distinct. (Fig. 530.) A depression is found below the middle of the leg at the outer side of the tibia, into which the foot fitted. The leg is thinner than normal in this region. (Fig. 531.) The description given by Kustner applies very closely to congenital talipes calcaneus, except that in the latter the extension of the foot is not always so pro- nounced as it was in Kiistner's cases, but the eversion and abduction of the front of the foot more so, so that the foot is bent sharply outward at Chopart's joint; the toes are extended or clawed. (Fio-. 532.) 830 DISEASES OF THE ANKLE AND FOOT. Fig. 532. Congenital talipes calcaneo valgus, (v. Volkinann.) The cause of congenital flat-foot is without doubt usually that the foot becomes fixed in the abnormal position in utero. At the same time the knee may be flexed sharply, or the extended limb may be flexed upon the abdomen, or the feet may be interlocked. (See under Talipes Varus.) This fixation is certainly largely due to relative lack of space and of amniotic fluid. Further causes are defects of the fibula (Volkmann's "maldevelopment of the ankle-joint"), diseases of the central nervous system (congenital paralytic talipes valgus), and foetal rhachitis. (Schul- theiss.) The calcaneum has been found adhe- rent to the scaphoid or astragalus in some cases. (Holl.) Franke refers many cases to maldevelop- ment — primary disturbances of growth — and to abnormal insertion of the muscles. In one in- stance in which the foot was very flabby he found the tendon of the tibialis anticus inserted on the dorsum of the foot; improvement was obtained by shortening and shifting the tendon. The acquired form of flat-floot may be due to rhachitis. As is known, the weight of the body tends to evert the foot; if the bones are abnor- mally soft, they yield and become shaped in the direction of e version. Curvatures of the tibia and fibula often favor the valgus position, but the abduction of the rhachitic flat-foot is not always so marked as in the static form acquired later; more often the arch is flattened — that is, the condition is flattened foot [weak-foot of Whitman] rather than talipes valgus. Flat-foot also develops after paralysis, especially in children. Flere again it is usually the weight of the body which everts and abducts the foot. It follows most rapidly if the plantar flexors and invertors of the foot alone are affected; but it also occurs after complete paralysis of the foot. The ankle-joint is extended, the mediotarsal joint everted. When not in use and in the recumbent position the foot is extended and inverted by its own weight, and as a result becomes abnormally movable, even a flail-foot. Very exceptionally paralytic flat-foot develops, during disuse, after paralysis of the plantar flexors and invertors of the foot, from the active contraction of the evertors. The ankle-joint is then flexed at first and gradually becomes extended after the foot is used. Occasionally in such cases, if the patient does not walk upon the foot, the back part of the foot becomes strongly abducted and everted, while the front of the foot is extended by its own weight. Traumatic flat-foot may develop after fractures, dislocations, or injury of the tibialis anticus and the long flexors of the toes. (Vul- pius.) It is most commonly the result of fracture of the malleoli uniting with deformity. Static Flat-foot. — The most important of the acquired forms of flat- foot is the static flat-foot (pes valgus staticus or adolescentium). The CONTRACTURES AM> DEFORMITIES OF THE FOOT. *:;] terms static and adolescentium are used because the chief cause is the improper weighting of the foot (tarsalgia of adolescents, Gosselin) and because il develops most frequently during or soon after puberty. Mechanism of Origin of Static Flat-foot. — The function of the foot is that of a supporting arch, the weight of the body resting upon the astragalus. As the skeletal elements of the foot do not form a solid unit, hut are movable upon each other and act as an arch only in certain positions, the latter is merely a so-called bowstring arch. The ligaments which tra- verse the entire arch in the direction of the tendons and hind together various portions in the same direction, form the main resistance in pre- venting the arch from sinking. Such a structure is capable of move- ment within itself and also of becoming stable when the ligaments are put upon the stretch, provided that the edges of the individual elements on the convexity of the arch support each other. The factors concerned in this resistance are: 1. The tensile resistance (absolute strength) of the ligaments. 2. The incompressibility (retroactive resistance) of the bones. The muscles can also contribute to the tensile strength of the arch, and ordinarily do this, but not to the extent formerly supposed. Fig. 533. The main supports of the foot, according to H. v. Meyer. According to H. v. Meyer, the arch of the foot is supported in front mainly by the head of the third metatarsal, behind by the calcaneum, and is made up essentially of the third metatarsal and its cuneiform, the cuboid, and calcaneum. (Fig. 533.) The joint between the third cuneiform and the cuboid is the weakest point of the arch, as it deviates only 45 degrees from the curved plane of the arch instead of being per- pendicular to it. The resulting side strain, however, is transmitted to and resisted in turn by the scaphoid, astragalus, and calcaneum. From the astragalus the w T eight of the body is transmitted to the calcaneum and third metatarsal through the front of the calcaneum and cuboid and through the scaphoid. The lateral pressure at the front of the arch is distributed over a circle formed by the cuboid, base of the third meta- tarsal, third cuneiform, and scaphoid, the strength of the transverse arch of the front part of the metatarsals depending upon the transverse ligaments. If the weight of the body falls to the inner side of the third 832 DISEASES OF THE ANKLE AND FOOT. toe, it is supported by the three inner toes, and if to the outer side, by the three outer toes. According to the statistics, the static flat-foot develops between the sixteenth and twentieth year in by far the greater number of cases. It is found chiefly in delicate, rapidly growing individuals with weak muscles who are obliged to do hard work, especially to stand or walk for long periods — namely, bakers, waiters, locksmiths, factory-hands, servants, errand-boys, porters, etc. It occurs therefore in the class of patients in which genu valgum is most frequent. It is seen also occa- sionally in well-developed individuals who carry heavy weights or who become rapidly corpulent, especially women. It is due essentially therefore to a disparity between the power of resistance of the foot and the demands made upon it. A Fig. 534. b a b c. Triangle of the foot. A. Projection of mid-point of astragalus, a c. Line of great toe. cb. Line of little toe. a b. Line of metatarsus. A d. Distance of the mid-point of astragalus (in the projection) from the line of great toe. A e. Distance from line of little toe. A a, A b, Ac. Projection of lines from the angles of the foot triangle to the mid-point of astragalus. A a. Line of support to the great toe. A b. Line of support to the little toe. A c. Line of support to the heel. A a. Middle line of the foot. A P. Plane of flexion of the trochlea. (H. v. Meyer.) For the production of flat-foot Henke assumes a relaxation of the muscles as the primary cause; Hiiter, an inequality in the growth of the bones; Stromeyer, atony of the plantar fascia and ligaments; Le Forte and Tillaux, weakening and stretching of the same; Lorenz, a primary weakening of an outer arch which supports the inner arch and astrag- alus, and secondarily of the inner arch. v. Meyer denies the sinking of the arch as the plantar ligaments are not lengthened, the joints are not separated and the inner border of the foot is not lengthened but normal, while the outer border of the foot is shortened; the chief cause is the valgus position. In the normal foot a vertical projection of the middle point, namely, the trochlea of the astragalus, falls in the triangle of the CONTRACTURES AND DEFORMITIES OF THE FOOT. 833 foot formed by the middle point of the heel and tin- heads of the first and fifth metatarsals. (Fig. 534, A.) In flat-foot this projection falls to the inner side of the triangle (Fig. .">:>4, b), and at the same time the middle point of the trochlea of the astragalus approaches the ground. (Fig. 535.) In the oases examined by v. Meyer the average valgus deviation of the foot from the axis of the trochlea was 45 degrees. In flat-foot therefore the arch does not sink downward hut inward. By the weight of the body the astragalus is pressed downward and for- ward upon the calcaneum and at the same time rotated inward about the oblique axis of the calcaneo-astragaloid joint. The outer end of the transverse axis of the trochlea (in the ankle-joint) thus becomes lowered. The beginning of flat-foot is an exaggeration of this motion ; in other words, excessive rotation of the astragalus. The more the astragalus sinks and the head is rotated inw T ard, the more the outer Fig. 535. dA & A A. Line of vertical projection of mid-point of astragalus. end of the transverse axis becomes depressed. This transverse axis thus assumes an oblique position with respect to the other tarsals, but as it must remain horizontal in the ankle-joint, this means that the foot is rotated outward and everted on the astragalus. Hence the line of gravity falls more and more to the inner side of the foot. In reality therefore the astragalus remains at rest while the foot deviates outward. The more the calcaneum deviates outward, the more the sustentaculum slips outward and forward under the head of the astragalus toward the line of gravity and is pressed downward, while the body of the calcaneum is pushed upward and backward by the counterpressure of the ground. As any backward deviation of the calcaneum is checked by the calcaneofibular fasciculus of the external lateral ligament, the bone is forced upward behind and downward in front by the forward and inward rotation of the fibula with the astrag- alus. The arch of the foot thus becomes flattened. This rotation of the calcaneum on the astragalus and leg can only take place if the ankle- Vol. III.— 53 834 DISEASES OF THE ANKLE AXD FOOT. joint is extended (pes flexus [extensus] Henke). But as the front of the foot cannot be extended when on the ground the extension takes place in Chopart's joint. The head of the astragalus rotating inward and forward pushes the scaphoid, which is firmly united to the calcaneum, forward and outward, and this pressure transmitted to the cuneiforms and cuboid forces that part of the foot in front of Chopart's joint out- ward (pes abductus, Henke). v. Meyer (and Lorenz) agrees with Henke as to the nature of the subluxation taking place in the joints, but explains the mechanism differently. He regards the extension of the ankle- joint as the result, not of active contraction of the calf muscles, but of the valgus position and the sinking (reflexion) of the front of the calca- neum. Henke, Lorenz, and v. Meyer agree in assuming that flat-foot is due to excessive eversion and abduction. According to v. Meyer, the shifting of the joint-surfaces upon each other takes place by gradual remodelling of the bones accompanied by stretching and possibly partial tearing of the ligaments. Fig. 536. Outer view of flat-foot. (Lorenz.) Every time the foot is overweighted the astragalus is rotated down- ward and inward, and if this is repeated often enough the bones yield, the ligaments become stretched, and the valgus position follows. Im- proper weighting of the foot is even more important than overweight- ing. This happens if the foot is turned outward in walking; for in order to extend the foot the astragalus then has to be rotated inward abnormally. The improper attitude which a tired person is apt to assume, the "habitual" posture of Hoffa, "the attitude of rest" of Armandale, contributes even more largely to alter the direction of pressure. The legs may be spread apart with the knees slightly flexed and the feet turned outward; or the person leans against a wall with the feet turned outward and planted well forward, a position frequently assumed by waiters who go to sleep while standing. In these postures the weight falls to the inner side of the foot, which becomes more and more abducted and everted. Directly or indirectly this tends gradually to stretch the ligaments and alter the shape of the bones. Such changes CONTRACTURES AND DEFORMITIES OF THE /nor. 835 can unquestionably take plate in bones of normal solidity, but the coexistence of coxa vara, genu valgum, and talipes valgus in the same person and the frequent occurrence of the two latter under the same conditions of life would seem to indicate a certain predisposition. Pathological Anatomy. — The changes in the bones and soft parts have been described most accurately by Lorenz, with whose description Fig. 537. Inner view of flat-foot. (Lorenz.) v. Meyer, Symington and others agree in essentials. The tip of the exter- nal malleolus is rounded and flattened; in severe cases the malleolus is broadened and the tip bent out by the pressure of the calcaneum. (Fig. 536.) The astragalus is extended, so that only the posterior part of the trochlea articulates with the tibia and fibula. (Fig. 537.) The car- tilage on the anterior portion is atrophic or absent; also on the front Fig. 538. Astragalus of flat-foot. (Lorenz.) portion of the lateral facets. The head projects forward and down- ward, and the scaphoid is displaced outward upon it. In very severe cases the scaphoid may be dislocated upward upon it and even articu- late with the body of the astragalus by a new joint. In other cases there is new growth of bone and periosteum on the upper outer surface of the head of the astragalus (Fig. 538) preventing further displacement 836 DISEASES OF THE ANKLE AND FOOT. of the scaphoid. On the under surface of the astragalus the changes are less important, although the cartilage on the under surface of the head may be obliterated if it no longer articulates with the sustentacu- lum. ( Fig. 539.) On the calcaneum the cartilage disappears from the outer half of the posterior margin where it is no longer in contact with the astragalus. The facet on the sustentaculum gradually disap- pears. A hollow facet may form on the inner, upper edge of the neck to articulate with the scaphoid. The cuboid becomes more wedge- shaped. The outer sagittal diameter of the scaphoid may be so decreased that the bone forms a wedge with apex upward and outward. If the scaphoid is displaced upward and outward on the astragalus, the cartilage on the posterior surface is present only on the lower inner portion. Above, the denuded bone is roughened and articulates with Fig. 539. Astragalus and os calcis of flat-foot: a, line of junction of intact cartilage c, and denuded surface 6, on the trochlea. The sustentaculum e lies opposite the sulcus tali instead of the articular facet d. (Lorenz.) a new facet on the body of the astragalus and neck of the calcaneum. The facets for the cuneiforms on the anterior surface of the scaphoid are displaced upward and outward. The changes in the cuneiforms and metatarsals are insignificant. The plantar ligaments, according to Lorenz, are lengthened and, for the most part, thickened and hyper- trophic. The external calcaneo-astragaloid ligament is appreciably lengthened (1 inch instead of f^ inch). By subluxation of the scaphoid it may become wedged between the astragalus, calcaneum and scaphoid, and destroyed. The calcaneo-fibular fasciculus of the external lateral ligament may be lengthened, or destroyed by the nearthrosis between the fibula and calcaneum. The combined deltoid and navicular (lig. tibiocalcaneo naviculare) ligaments are stretched (If to 2| inch, instead of normal If inch), as demonstrated by Symington; also the [long] calcaneocuboid ligament. The sharp contrast between these data and v. Meyer's assertion that CONTRACTURES AND DEFORMITIES OF THE FOOT. 837 the plantar ligaments are not lengthened is Lessened by the admission of Lorenz that the sinking of the arch is due "to pressure atrophy of the dorsal ligaments on the wedge-shaped bones of the arch," and that of v. Meyer thai there i- ;i secondary stretching of the ligaments favoring increase of the deformity. The changes in the muscles are disregarded by recent authors. Flat-foot, or talipes valgus, is to lie sharply distinguished from pes planus. In both deformities the sole is flattened and the scaphoid abnormally low, but in pes planus, which is merely lowering of the normal arch, the valgus position or pathological eversion and abduction of the foot are absent. Some authors regard pes planus as an indication of arrested development or racial peculiarity (negroes, Jews); others believe that it is due to overweighting. Pes planus does not pre- dispose to pes valgus and is usually not troublesome. The amount Fig. 540. --'">-. «r , ■- Ss* il \ ' m Footprints in flat-foot. (v. Voikmann.) of flattening can be ascertained approximately according to v. Voik- mann by making a charcoal impression of the foot (Fig. 540) or by having the patient make footprints on the floor. For scientific purposes these methods are inaccurate, as they disregard the relation of the foot to the leg. Symptoms and Diagnosis. — In recent cases the differentiation of the various forms of flat-foot is not difficult. Congenital flat-foot is easilv recognized from the above description, at least in children; also the rhachitic form, which is usually accompanied by other symptoms of the disease and furthermore produces little disturbance. The child may tire easily and exceptionally complain of slight pain which disappears with rest. There is never any actual contracture or fixation such as is seen in the static form. In older cases in which the congenital merges into the static form the differentiation of the two is more difficult. The paralytic form is distinguishable by the history, the paralysis and atrophy 838 DISEASES OF THE ANKLE AND FOOT. Fig. 541. of the muscle, the looseness of the joints, and the facility with which the deformity can be corrected. The symptoms of traumatic flat-foot vary according to the nature of the injury. The diagnosis is usually easy from the history and local conditions; it is more difficult if displacement of the bones or laceration of the ligaments was slight and the flat-foot existed primarily or devel- oped soon afterward. In a case of well-marked static flat-foot the symptoms are characteristic. Viewed from behind, the foot is seen to be abducted and everted, the prolonged axis of the leg passes through or to the inner side of the inner bor- der of the foot; the internal malleolus projects prominently. (Fig- 541.) The outward de- viation of the entire foot if marked may resem- ble outward displacement of the lower epiphysis of the tibia. Trendelenburg called particular attention to this deviation. In the erect posi- tion the foot appears longer and broader, and the arch and sole flatter. The inner border of the foot may be in contact with the floor throughout and even convex inward. Between it and the prominent internal malleolus are two marked projections, the head of the astra- galus and below and farther forward the tuber- osity of the scaphoid. (Fig- 542.) The outer border of the foot is concave in marked cases and may be raised from the ground. The heel projects more prominently outward and backward. The tendo Achillis is usually stretched tightly and is outlined more dis- tinctly. The metatarsus is often adducted, the toes usually extended, and the great toe sometimes abducted. Hallux valgus and in- growing toenail are frequent accompaniments. The diagnosis of flat-foot in a well-developed case is easy. To the inexperienced a case seen before the flattening of the sole was pro- nounced might present difficulties, but in such the valgus-position would be conclusive. Hoffa has given the name "bent-foot" (Knick- fuss) to this position. The foot is still arched, but its front portion is strongly abducted and everted. The eversion is proportional to the rotation of the astragalus. The outward deviation of the heel is par- ticularly noticeable from behind. The "bent-foot" may continue as such through life, but as a rule represents an early stage of flat-foot. The discomfort is usually greatest at the beginning, but does not always correspond to the degree of deformity. The pain and fatigue are increased by walking and especially by long standing; sometimes the pain develops suddenly, as after dancing, long walks, or protracted standing. Localized points of tenderness are found most frequently Talipes valgus. (Kirmisson.) CONTRACTURES ASD DEFORMITIES OF THE FOOT. 839 at tht' tuberosity of the scaphoid, the head of the astragalus, and the astragalonavicular articulation, corresponding somevt hal to the course of the inferior calcaneonavicular ligament; Less often below and in front of the external malleolus at the front of the calcaneum due to pressure of thf edge of astragalus — and on the dorsum at the astragalonavicular articulation. Very frequently the entire heel, especially the under sur- face, is painful, less often the metatarsophalangeal joints, notably that of the great toe. The arch of the foot may appear normal or be dis- tinctly flattened. But the excessive eversion of the foot is always recognizable. In very mild cases attended with only slight pain, motion of the foot is free, only forced passive inversion and eversion being painful. While standing still the patient shifts from one foot to the other, contracting the extensors, the tibialis anticus, the peronei or the calf muscles alter- Fig. 542. Talipes valgus. nately. If the foot is very painful, it is held firmly abducted and everted with the muscles tense; actively flexion and extension are limited but' free passively except in the severest cases. At first the pain and stiffness follow only after prolonged use of the foot, and disappear partially or completely with rest; later they become permanent and are increased by overexertion. Many patients complain of painful cramps in the feet or calves of the leg at night, with the stiffness and pain most marked after resting or in the morning. Sometimes the ankles are swollen slightly and suggest an inflammation of the ioint or rheumatism, and are treated as such. The contracture sometimes develops slowly, sometimes very rapidly and is often extremely painful. Its etiology has been a matter of great dispute. The proper explanation is to be found in the irritation pro- duced by displacement and excessive rotation of the joints. The liga- 840 DISEASES OF THE AXKLE AND FOOT. merits, especially the inferior calcaneonavicular ligament, and the cap- sules are stretched and torn, and the periosteum irritated at certain points. As an expression of this irritation we find exostoses in the later stages, always at the same points. As this traumatic irritation never produces an actual inflammation, the term "inflammatory" flat-foot has been properly discarded. It is painful, however, and thus causes a reflex spastic contracture, analogous to the contracture due to arthritis. From this it can be understood how only the evertors and invertors are contracted in mild cases, and all the muscles of the foot in severe Fig. 543. Fig. 544. V,> -5s3-y^' An attitude thai simulates the flat-foot. (See Fig. 544.) (Whitman.) Fig. 544 compared with Fig. 543 illustrates the voluntary protection of the foot from over- strain. (Whitman.) cases. Where such fixation takes place suddenly the term acute flat- foot has been applied; but if we regard this fixation as a reflex contrac- ture the term talipes valgus contractus is more correct. It is important to remember that the contracture very often develops at the beginning of flat-foot, before the arch has become flattened to any extent, and that it may follow very suddenly after great fatigue. This, together with the existence of painful stiffness, points of tenderness, and a slight valgus position, excludes periostitis, neuralgia, or articular rheumatism. In older people arthritis deformans and gout may give very similar symp- toms. Pal has recently called attention to the fact that the " meralgia CONTRACTURES AND DEFORMITIES of THE FOOT. 841 paraesthetica " described by Bernhardt — paramnesias in the area of the external cutaneous — and sciatica are referable to Hat-fool and disappear after appropriate treatment of the latter. On careful examination of the foot the diagnosis is usually simple at the outset of the affection unless accompanied by the effects of sprains or fractures of the malleoli. In many instances the pain ceases and the stiffness disappears after the bones and joints have accommodated themselves to the changed position. But in the majority of cases more or less stillness persists, e version and inversion are limited, the muscles may undergo nutritive shortening so that the tendons of the peronei are displaced forward over the outer malleolus; the hones and joints are Fig. 545. Fig. 546. Illustrating the involuntary-adduction of the forefoot, due to the obliquity of the bearing surface of the metatarsus in the proper attitude for walking. (Whitman.) The improper attitute of outward rotation, in which there is disuse of the leverage function. (Whitman.) deformed by destruction of the cartilage and growth of the periosteum. The joints may be slightly movable or ankylosed. The gait is then heavy and inelastic. The amount of disturbance produced depends more upon the degree of valgus than on the flattening of the arch. If the muscles are well developed and the valgus slight, the disturbance is often trifling. Overexertion may produce exacerbations. Although varicose veins and "sweat-foot" are frequently combined with flat-foot they usually precede it, the flat-foot developing later as the muscles become weakened by the circulatory disturbances caused by the dilated veins (v. Lesser, Thomaszewski). Many authors deny this connection between the three affections. 842 DISEASES OF THE ANKLE AND FOOT. Fig. 547. There is also a form of flat-foot in which the sole is convex. When the deep muscles of the calf, the peronei and the plantar muscles have become tired in walking, the foot can be extended only by the triceps surse (gastrocnemius and soleus); in consequence the arch sinks and becomes convex downward in Chopart's joint as the weight is thrown on the toes. Walking when the foot is tired is therefore of unusual significance with reference to this form of flat-foot. (Nicoladoni.) Treatment. — The treatment of congenital flat-foot is the same as that of congenital talipes varus, namely, massage, frequent passive adduction and inversion or forcible correction and permanent immobilization in inversion and extension in a permanent or removable splint. The rhachitic flat-foot if mild recovers spontaneously like other rha- chitic curvatures. The severer cases should be supported by means of apparatus and shoe-plates, or rectified by forcible correction and immobilized and later treated by mass- age and apparatus. General treatment of the rhachitis is understood. In the case of acquired static flat-foot the prophylaxis is important. During working- hours the patient should walk with the toes forward or, better, turned in, and while standing turn the toes slightly inward, and if possible lift himself at intervals upon the toes to strengthen the muscles and increase the circulation. Long standing should be avoided and the feet rested as much as pos- sible. Gymnastic exercises combined with massage are the most valuable means of pre- venting and curing flat-foot in the first stages. Massage should be directed chiefly to the muscles of the sole and leg, especially the tibialis posticus and other calf muscles. The gymnastic exercises consist in rising upon the toes with the feet turned in; standing upon the heel with the feet turned in strongly; squatting with the weight on the heel and The proper relation of the sole to the foot turned in ; rotating the foot inward the shape of the foot, a, outline of wn ij e s i tt i ng with the knee extended, with sole; B, outline of foo^; C, imprint . . ° „ , , of foot. (Whitman.) and without counterpressure of the physi- cian's hand ; in fact, any exercise which tends to strengthen the invertors. Among more intelligent patients these measures often give grateful results. If possible, an injurious occupation should be exchanged for one less so or even beneficial in requiring toe-work. The shoe is very important; it should not be loose nor tight (hallux valgus!) and should allow free play of the toes. Lorenz, H. v. Meyer, CONTRACTURES AND DEFORMITIES OF THE FOOT. 843 and others recommend high heels. With most orthopaedists and sur- geons we believe this is wrong, and recommend a low, broad heel. Nor can we agree with Ellis in doing away with the heel entirely and raising the front of the foot. To support the arch the shoe is raised on Fig. 548. Fig. 549. Fig. 550 Flat-foot shoe. (After Miller and Thomas.) Beely's flat-foot shoe. (Hoffa.) the inner side (Fig. 548) or a plate is worn in the shoe, the latter being generally preferred. The two are also combined. Beely extends the heel forward and inward. (Figs. 549, 550.) Lorenz raises the entire Fig. 551. Hoffa's foot-brace. inner border of the foot, the heel of the shoe extending forward to the calcaneocuboid articulation, with a depression inside of the shoe at the outer side for the calcaneum. Meyer makes this depression at the inner side of the heel so as to force the calcaneum inward. Plates 844 DISEASES OF THE ANKLE AND FOOT. made of felt, cork, leather, rubber, or other such material are ineffectual; they force the foot outward without supporting it. A plate should support the entire arch, and should therefore have the normal arch of the sole, extending from the heel to the ball of the foot and from one side to the other. (Figs. 551 , 552.) The outer edge should be bent up slightly to prevent the foot from slipping outward. If properly shaped and fastened in the shoe, it produces no discomfort. L. Heidenhain Fig. 553. A, the astragalonavicular joint. The internal flange of the brace should rise well above all the prominent bones to a point about half an inch below the malleolus. (Whitman.) Fig. 554. Fig. 555. B, the calcaneocuboid junction. The external flange extends from the centre of the heel to a point just behind the base of the fifth metatarsal bone. (Whitman.) C, the great toe-joint; D, the centre of the heel. (Whitman.) makes a large plate of the size of the foot and shaped after a plaster model. The suggestions of the American orthopaedists (Whitman (Figs. 553-555), Dane, Sydney, Roberts) are particularly valuable. The best material is sheet steel (Xo. 18-20 gauge) or aluminnm-bronze; celluloid and durana have also been recommended recently. The plate is moulded upon a wax or plaster impression of the arch of the CONTRACTURES AM) DEFORMITIES OF THE FOOT. £45 foot shaped up somewhat to increase the arch. In very severe a this increase has to be effected gradually through several weeks before the normal arch is attained. To obtain the form of the tool when inverted, arched and weighted, Lange binds a cotton pad, corresponding to the arch, on the affected Fool and over this a plaster splint to above tin- malleoli. The patient then stands with the foot on an inclined surface, having a strip to prevent the foot from slipping sideways, till the plaster hardens. It is then cut off and a east made of it. over which the plate is moulded. The plate should be fastened in the shoe. Marci- nowski recommends that a side leg-brace be attached to the plate in severe cases to prevent the plate from slipping and thus possibly twisting the foot outward. A well-fitting plate relieves the discomfort rapidly and in time restores the arch of the foot. It has to be worn permanently unless a cure is possible by means of massage and gymnastic exercises. Recently operations have been combined with this treatment: Hoffa assumes that the tendon of the tibialis posticus is stretched, and so shortens it; Lange, Franke and others have performed the same operation success- fully. Nicoladoni splits the tendo Achillis and sutures one-half of it to the tendon of the tibialis posticus. E. Miiller has separated the tendon of the tibialis anticus from its insertion and sutured it with wire to the scaphoid through a tunnel cut in the bone. A plate is not effectual unless the bones are movable, so that the foot should be mobilized forcibly, if the bones are fixed, before adjusting the plate. The spastic contracture in acute contracted flat-foot is relieved by hot compresses, rest, and massage. Severe contracture is overcome more rapidly by immobilizing the foot in maximal inversion under local cocaine or general anaesthesia. In from four to ten minutes after injecting grain | to f (0.02-0.05 gm.) of cocaine into the astragalo- navicular joint the foot can usually be moved actively and passively without pain. The plaster-splint is worn for three weeks. In older cases with slirinkage of the soft parts and deformation of the bones and joints, forcible correction should be carried out under anaesthesia. With the foot held extended it is first adducted; then it is moved in all direc- tions and again adducted and inverted stronglv, then flexed while in this position and moved again in all directions. If the tendo Achillis is short and tense and interferes with the manipulation, it should be divided. In spite of the breaking up of adhesions and necessary tearing of the soft parts there is little reaction. The patient can go about on crutches in the plaster-splint after a few days. In three weeks the splint is removed, the foot massaged and moved, a previously made plate is worn in the shoe, and gymnastic exercises performed systematically; it may be necessary to repeat the manipulation in order to complete the correction. For severe and old non-rectifiable cases operations have been pro- posed aiming to restore the arch by removing portions of the bones on the inner side of the foot. Golding Bird removes the scaphoid, Vogt the astragalus. Ogston resects the head of the astragalus and the articular g46 DISEASES OF THE ANKLE AND FOOT. surface of the scaphoid, and sutures the two bones together to obtain bony union; the operation has been repeatedly successful. Stokes resects a wedge from the head and neck of the astragalus. Schwartz chisels a wedge from the inner side of the foot without regard to the joints, chiefly from the astragalus and scaphoid. Excision of a wedge is the most practical procedure; the bones are sutured with wire. To avoid the stiffening of the arch produced by the above operations Tren- delenburg and Hahn prefer to divide the tibia and fibula just above the ankle-joint through an inner and outer incision, overcorrect the deformity and apply a plaster-splint, v. Eiselsberg divides the calcaneum from before and below upward and backward and shifts the posterior frag- ment downward and forward to increase the angle formed by the calcaneum with the ground, and if this is not sufficient removes a wedge from the bone with base below. If the calcaneum is everted, the posterior fragment is shifted inward at the same time. The results are favorably reported by some authors, but unfavorably by Marcinowski in three cases in v. Mikulicz' clinic. Tendon transplantation has been tried repeatedly with success in paralytic flat-foot. The tendon of the paralyzed tibialis anticus has been sutured to the extensor hallucis, peroneus longus or tertius, etc.; the tendons have also been shifted subperiosteally, as proposed by Lange, for example, the tendon of the peroneus longus carried behind the tendo Achillis to the inner border of the foot and sutured to the calcaneum. (Drobnik, Vulpius; compare the operations in Talipes Calcaneus and Calcaneo valgus.) These procedures were usually beneficial and are worthy of trial. (Nicoladoni.) Arthrodesis, performed many times on the tibiotarsal joint, to be effectual in these cases generally has to include also the calcaneo- astragaloid or the mediotarsal joint, according to which shows the greatest abnormal mobility. For the ankle-joint Samter's incision is preferable; a posterior longitudinal incision with division of the tendo Achillis and subsequent suture. The tibiotarsal and mediotarsal joints are best reached through an anterior curved incision. Talipes Calcaneus. — Talipes calcaneus is characterized by marked downward projection of the heel. According to Nicoladoni, we dis- tinguish two main types: 1. Pes for talipes) calcaneus sursum nexus, due to pronounced flexion of the foot. It may be congenital, or acquired (a) through paralysis; (h) through pathological processes in or about the ankle-joint. 2. Pes (or talipes) calcaneus sensu strictiori, due purely to the low position of the heel. It is always acquired. In congenital talipes calcaneus sursum flexus dorsal flexion is com- monly very pronounced; the muscles of the leg and foot are normal, the movements of the limb are prompt. (Fig. 556.) Every effort to extend the foot is prevented by the visible tension of the tendons on the dorsum. Like talipes varus and valgus, the deformity is unquestionably due to intrauterine pressure resulting from faulty position of the foot and lack of space. Very often the foot is also everted and abducted, talipes calcaneovalgus; sometimes the valgus, sometimes the calcaneus position VoyrilACTl'llES AM) DEFORMITIES OF THE FOOT. 847 predominating. The sole is usually flattened. The distinction made between talipes valgus with flexion and talipes calcaneus is therefore often arbitrary. The anatomical changes in the two conditions are very similar. (Messner, Kustner, see page 829.) The paralytic form usually results secondarily from the weighting of the foot after paralysis of the plantar flexors, rarely primarily from active contraction of the dorsal flexors. The mode of development, according to v. Volkmann, is that the foot is flexed by the body-weight, if used in walking, as it is no longer held by the paralyzed calf muscles, and usually becomes more or less everted and abducted at the same time. Fig. 557.) If the patient takes short steps and plants the entire foot and not the heel first, then only the weight acts, and flexion is limited Fig. 556. Fig. 557. Congenital talipes calcaneus. (Xicoladoni.) ^ Paralytic talipes calcaneus. (Hoffa.) by the check action of the ligaments, etc. This limitation diminishes, however, as the shape of the bones gradually changes and the ligaments and tendons become stretched and shifted; the foot is then flexed strongly at each step. If the patient takes long steps, the back of the heel strikes the ground and the calcaneum is twisted forward. This happens espe- cially if the knee is hyperextended in swinging the leg forward, as it occurs, for example, with paralysis of the quadriceps. The calcaneum may thus become bent forward. If the dorsal flexors are also paralyzed or weakened, the front part of the foot is apt to be bent down gradually by its own weight. The foot thus becomes a paralytic talipes cavus. Flexion is always retained in the ankle-joint, however, even if talipes cavus develops. In the talipes calcaneus sensu strictiori of Xicoladoni the heel points directly downward, the dorsum of the foot is at an angle 848 DISEASES OF THE ANKLE AND FOOT. of slightly more than 90 degrees to the leg, the sole is highly arched,, and the patient walks upon the heel and the ball of the great and little toe. The ankle-joint is not fixed in extreme flexion, but can still be flexed slightly. Yet according to Nicoladoni any movement of flexion is not and never was possible in the ankle-joint. The foot is bent upon itself at two points in the sole: at the tarsometatarsal joints and beneath the front part of the calcaneum. The posterior process of the calcaneum becomes an inferior process, so that the heel is less prominent than usual. (Fig. 558.) According to Nicoladoni, the condition is due to paralysis of the muscles of the calf, the peronei, dorsal flexors, and plantar muscles being intact. Every time the foot is raised and lowered the calcaneum is pulled upon by the plantar muscles until in the course of years the foot and its bones resemble in form the foot of a Chinese woman. Fig. 558 Talipes (pes) calcaneus sensu strictiori. (v. Bruns.) Treatment. — The congenital form merely requires passive move- ments, energetic manipulation, and massage. Stubborn cases demand correction under amesthesia and immobilization. Very severe or old cases are overcome more rapidly by dividing the dorsal tendons. In the paralytic cases, to prevent the excessive flexion, v. Volkmann replaces the action of the paralyzed muscles by strong elastic bands. (Fig. 559.) Judson applies an outer brace along the leg with an adjust- able, hinged foot-plate or sheath permitting full extension, but flexion only to a right angle. Hoffa's apparatus (Fig. 560) consists of a Hessing laced leather foot-sheath fastened to a foot-plate which is hinged at the ankle to two lateral braces extending to and fastened below the knee by a strap; the eversion and flexion of the foot are overcome by means of appropriately attached rubber bands. Such apparatus may also be used for the second type of talipes calcaneus. The treatment of the severe forms combined with talipes cavus will be described under the latter. CONTRACTURES AND DEFORMITIES OF THE FOOT. 849 In the paralytic cases Willet shortens the tendo Achillis. The opera- tion has been performed by others with varying results. Among 28 cases, Gibney obtained 17 complete results — even in the absence of primary union; 8 were satisfactory, and 3 were not improved. The result apparently depends less upon the strength of the sutured tendon than the condition of the muscles; if the gastrocnemius and soleus are completely paralyzed and atrophied, they are more liable to stretch than if only partially paralyzed. Hence the shortening of the tendons is more likely to be successful if the muscles are only partially atrophic. Partial degeneration of the calf muscles is apparently the more frequent occurrence. The permanency of the results still has to be proved. Fig. 559. Fig. 560 Volkmann's apparatus for talipes calcaneus. fHoffa.) Hoffa's apparatus for talipes calcaneus. Tendon transplantation, as employed first by Xicoladoni for paralysis of the calf muscles, apparently gives the best results if the muscles are only partially paralyzed and the tendons can be shortened at the time of operation. If the paralysis is extensive and the foot very loose, arthro- desis of the tibiotarsal joint is preferable, and also of the calcaneo-astrag- aloid or mediotarsal if necessary. It is customary to fix the foot at a right angle to the leg. In cases where the leg was much shortened it has been lengthened by the Wladimiroff-Mikulicz resection method. HofTa obtained a very good result in a severe case of talipes calcaneus by dividing the tuberosity of the calcaneum obliquely, shifting it upward Vol. III.— 54 850 DISEASES OF THE ANKLE AND FOOT. and backward, and shortening the tendo Achillis. Laurent obtained an excellent result by resecting the scaphoid and cuboid. Talipes Cavus (Hollow or contracted foot, pes excavatus, pes arcu- atus, talipes percavus, talipes plantaris, non-deforming club-foot). — The term talipes cavus is applied to abnormal arching of the foot. The arching in pes calcaneus sensu strictiori is present from the first, Fig. 561. Fig. 562. Beely's correction apparatus for hollow-foot. (Hoffa.) and is a genuine talipes cavus. Associated with talipes equinus or equinovarus and congenital paralytic talipes calcaneus it is usually not an essential but secondary condition. The pied creux of the French (Duchenne; Klauenhohlfuss) is a variety of paralytic talipes cavus due to paralysis of the interossei, lumbricales, and muscles inserted in the sesamoid bones of the great toe (flexor brevis and adductor hallucis). The toes then assume a peculiar claw attitude and the metatarsus becomes depressed. On first thought it suggests talipes equinus but for the fact that the tibiotarsal joint is not extended, but on the contrary becomes increas- ingly flexed the more the metatarsals are depressed and the arch of the sole is raised. Other non-paralytic varieties are also seen. Some are congenital and pos- sibly due to intrauterine pressure. According to Hoffa, they are also hereditary. Short shoes may produce hollow feet in children, analo- gous to the feet of Chinese women. In severe cases of hollow-foot there may be considerable discomfort from tarsalgia and painful callosities. In children the deformity may be overcome by manual correction or with the aid of Heusner's appa- Beely's correction apparatus for hollow- foot. (Hoffa.) CONTRACTURES AND DEFORMITIES OF THE TOES. 851 ratus (Ringhebels). If necessary, the superficial plantar fascia can t>e divided siibcutaneously or openly and the foot immobilized, after cor- rection on a straight splint or in plaster. Of the various apparatus proposed for gradual or forcible correction, Beely's is the most practical. After the position is rectified (Fig. 561) it is maintained at night in a frame of similar form by means of elastic hands. ( Fig. 562.) CONTRACTURES AND DEFORMITIES OF THE TOES. Hallux Valgus. — The most important of the deformities of the toes is the abduction of the hallux in the metatarsophalangeal joint. As a rule it is undoubtedly due to purely mechanical causes, namely, improper shoes. In children who have never worn stiff shoes or in individuals Fig. 563. Fig. 564. Fig. 565. Proper shapes. Improper shape. (H. v. Meyer.) who have always gone barefooted the great toe is in line with or turns slightly inward from the inner border of the foot. This is the normal position. In most people the great toe, contrary to the aesthetic require-' ments of the ancient Greeks, is the longest. Shoes which are too narrow or too pointed crowd the great toe toward the middle line of the foot. A shoe may be pointed, but the point should correspond to the great toe and give free play to all the toes. (Figs. 563 to 569.) The higher the heel, the more the foot is pushed forward and the toes crowded together. Hallux valgus is therefore very rare in children, and more frequent among the wealthier classes in cities, especially among women who wear narrow-pointed shoes from vanity, than among country people. The anatomical changes were first studied by Broca, more recently by Delarochaulion, Payr, Ajevoli, Heubach, and others. In marked cases the phalanx articulates with only the outer half of the articular surface of the head of the metatarsal; the latter is thickened outward 852 DISEASES OF THE ANKLE AND FOOT. and its cartilaginous surface extended. The inner half of the articular surface is often separated from the outer half by a deep groove and its cartilage is defective or absent. The exostosis described by v. Volkmann is a growth of the tuberosity behind the joint, due to the irritation. The sesamoid bones are both dislocated outward. The metatarsal deviates inward in severe cases so that the foot is abnormally wide. It may be Fir,. 566. Fm. 567. Normal feet. Fig. 568 Proper soles for normal feet. Fig. 569- Shoemaker's feet. (Whitman.) Shoemaker's snles. also rotated on its long axis with the phalanx till the upper surface faces inward. The articular surface of the phalanx is diagonal to the long axis. The outward displacement of the flexor and extensor tendons maintain or increase the deformity. After the condition has existed for some time the synovialis becomes thickened and covered with villous growths, the cartilage and bone are partly eroded, partly increased, CONTRACTURES AM) DEFORMITIES OF Till-! Tolls. 853 much the same as in arthritis deformans. The latter has therefore been improperly regarded as the cause of the valgus position. Fig. 570. Hallux valgus. (v. liruus.) Fig. 571. Fir.. 572. Hallux valgus. (Hoffa.) The toe may be abducted 70 or 80 degrees and lie above or beneath the second toe. (Figs. 571 and 572.) A callosity, clavns, or even per- 854 DISEASES OF THE ANKLE AND FOOT. niones, frequently develops at the inner side of the head of the first meta- tarsal, having beneath it a single or multilocular bursa, often communi- cating with the joint. The pain produced by the corn and bursa is increased if the latter becomes inflamed and suppurates. If the pus perforates outward, a fistula is left. As long as the latter remains open the pain may be moderate, but as soon as it becomes closed and retention occurs the pain becomes intense again. The pus may perforate into the joint, if there is already no communication, and cause suppuration of the joint. Lymphangitis and cellulitis occasionally follow and make the affection serious. Even without these complications the pain due to the arthritis deformans and the pressure of the shoe may be very severe. As v. Volkmann says, the patient's struggles with his shoemaker bring him no relief. Hammer-toe of the second toe and ingrowing toenail are frequent sequela?, the latter most frequently on the outer side of the great toe where it presses against the second toe, less often on the inner side. The gait is usually heavy and shuffling in marked cases as the foot cannot be lifted so as to clear the ground. This is true even if the arch of the foot is unaffected, and even more so if flat-foot develops, which happens very often with pronounced hallux valgus. Treatment. — The first principle of treatment in all cases is the wear- ing of proper shoes with low heels and plenty of room. For gradual correction of the deformity small splints with strips of adhesive plaster or rubber bands, and a number of apparatus, have been recommended. The most comfortable of these is a padded steel spring fastened on the inner side of the toe with adhesive plaster, to which the toe is bandaged. All splints and apparatus of this sort are very uncomfortable, are apt to cause pressure in the shoe, and act slowly. It is simpler and more effectual to correct the deformity forcibly and apply a plaster-splint. Even this does not succeed in severe cases or acts too slowly, so that various operations have been recommended. [Whitman suggests Holden's toepost, recommended by Walsham and Hughes, consisting of a thin metal upright plate fastened in the shoe, so as to separate the first and second toes and hold the former in an improved posi- tion. Also Sampson's tin toepost fastened to a cardboard inner sole. (Figs. 573 to 57(3.)] The oldest operative method is resection of the joint and excision of the sesamoid bones (Hamilton, Rose); it has been advocated again recently by Heubach. An incision along the inner side of the joint makes it possible to excise the corn and bursa at the same time, but it has the disadvantage of leaving a scar where it is most exposed to pressure. This can be obviated by making the incision between the first and second toes. Riedel asserts that the results of resection are good only if flat-foot exists, for otherwise the removal of the head of the metatarsal, one of the chief supports of the foot, is fol- lowed by very great disability. The head should therefore be pre- served and merely smoothed off, the exostoses chiselled off, and the base of the phalanx resected; or with Schede, one may merely excise the bursa and remove the part of the head not in contact with the phalanx. Any persisting valgus position is supposed not to produce any further CONTRACTURES AND DEFORMITIES OF THE TOES. 855 disturbance. The best method is thai of Barker and Reverdin, recently recommended by Riedel, namely, removal of the exostosis and of a wedge from the metatarsal just above the head. In some cases the exostosis liinv be left. Fig. 573. E c H r' Making the pattern fur a toepost. A heavy piece of paper folded once along the line A B. A D E and B C F are cut away, leaving the tongue A D C B. A D should equal the depth of the shoe at that point, and A B should be as wide as the length of the slit in the cardboard inner sole. The tongue is inserted in the slit, and the bases folded back and cut away to conform to the front of the inner sole. When removed and straightened out this forms the pattern in Fig. 574. Fig. 574. E E D D H --nC F E Pattern of paper from which the tin is cut. The edges D D and C C are to be turned in. folded along the dotted lines A B—D C and D C forming the toepost in Fig. 575. Tin is Fig. 575. Shows the toepost ready to be inserted into the cardboard inner sole. Rough points on the upper and under surfaces of the base, which are made by punching holes with an awl, hold the toepost to both the inner sole of the shoe and the cardboard inner sole. Fig. 576. Cardboard inner sole with toepost and foot adductor attached. (Sampson.) Hallux Varus. — Adduction of the great toe is very rare, and is seen almost exclusively in connection with other congenital or acquired deformities of the foot. The toe may be bound in position. Operation is almost never necessary. 856 DISEASES OF THE AXKLE AND FOOT. Lateral Contractures. — Lateral contractures of the other toes are rare, and are seen chiefly in the little toe, which becomes adducted from pressure of the shoe. The other toes may overlap from wearing improper shoes, cause pressure ulcers and ingrowing toenails, and be very trouble- some. They may be straightened forcibly and bandaged in place, but are often more willingly sacrificed. Flexion and Extension Contractures.— Flexion and extension con- tractures of the toes are accompaniments and sequela? of the various contractures of the foot, talipes valgus, equinus, varus, etc. Pure flexion contractures of the metatarsophalangeal and interphalangeal joints are mostly the result of paralyses (for example, severe talipes equinus), although also said to be congenital. The most common form of contracture is that in which the first phalanx is extended and the others flexed. Occasionally all the toes are affected and the sole of the foot is arched abnormally above the metatarsophalangeal joints as in hollow-foot. This is seen as the result of infantile spinal paralysis or the wearing of short shoes, especially with high heels, while the foot and toes are growing. The heads of the metatarsals project downward abnormally and painful callosities develop under them. Severe neu- ralgic pains affecting the metatarsus or even the tarsus may occur in people who have to stand or walk a great deal. Hammer-toe. — Hammer-toe, a flexion contracture of single toes, is more common. The first phalanx is extended, the second flexed, and the third either flexed or extended. It occurs most frequently in the second toe. It is rarely congenital, as some authors maintain, but usually due to improper shoes. It is more often caused by lateral deviation of the great toe from wearing narrow shoes, than by the press- ure of shoes which are too short. In hallux valgus the first toe gen- erally lies over the second and presses it downward and backward; if it lies under the second toe, the latter is merely extended in the metatarso- phalangeal joint. Sometimes the second and fourth are hammer-toes and lie over the others. As the toes thus deviate laterally at the same time they are arranged in two rows (chevauchement des orteils). This is positive evidence of pressure. Occasionally the flexion contracture is limited to the great toe. Usually the interphalangeal joint is then flexed; but it may be hyper- extended, while the flexion contracture is in the metatarsophalangeal joint. The occasional coexistence of hammer-toe and flat-foot is differently explained by various authors, some assuming the former, others the latter as primary. We have seen a few cases in which the hammer-toe was secondary. Hofmann calls this the club-toe position because the toes are adducted and flexed; it is most pronounced in the great toe, less so in the others. The front part of the foot is inverted and the arch flattened (club-toe flat-foot). The deformity is at first a temporary attitude of relief in painful conditions of the leg (flat-foot, affections of the knee), but later becomes fixed. The treatment is that of the underlying disease, CONTRACTURES AND DEFORMITIES OF THE TOES. 857 Slight flexion contractures are not noticed by the patient. In marked cases painful corns form on the sole under the head of the metatarsal, on die upper surface of the toe over the first interphalangeal joint, and often on the end of the toe close to the nail. A painful bursa often develops under the corn on the dorsum of the toe, suppurates, perforates outward and also communicates with the joint. The pressure of the shoe may be unbearable. Treatment. Sandals with elastic loops have been recommended for flexion contracture of all the toes. Konig divides the flexor tendon of the great toe and then has the patient wear a wooden sandal shaped to the sole of the foot, and bandaged firmly to hold the toes down; later it is worn only at night. It is adapted especially for the cases of contracture combined with talipes cavus. Single toes may be extended forcibly and bandaged with adhesive plaster to a small elastic metal splint covered with felt. Greater curvatures require operation. Division of the skin, tendons, and capsule on the flexor surface until the toes can be stretched, followed by immobilization for from three to four weeks, has also been recommended. The results are sometimes good, but then again the joints may be so deformed that the effect is only temporary. We prefer therefore to resect the joints through a dorsal incision and to excise the bursa and divide the flexor tendon. If the toe is so deformed or dis- placed as to be useless, amputation is preferable. ( lontraction of the plantar fascia and of the toes, analogous to Dupuy- tren's contraction, is very rare. Hoffa saw such in a patient twenty years old developing without apparent cause; there was a thickened band in both feet corresponding to the inner border of the plantar fascia. The severe pain which existed was relieved by excision. The specimen showed inflammation of the plantar fascia and spots of cartilaginous metaplasia. Ledderhose records cases of cicatricial nodules in the fascia due to laceration, the pain of which usually disappeared spon- taneously and rarely necessitated excision. Franke saw similar nodules, but painless, appearing after influenza, which he regarded as inflammatory and designated as a fasciitis plantaris. Metatarsalgia. — Metatarsalgia, a painful affection of the metatarsus first described by T. G. Morton, the etiology of which is similar to that of contractures of the toes, has been taken little account of in the German literature. After or in the absence of previous slight trauma, severe pain is felt in the region of the fourth metatarsophalangeal joint. It is usually increased by pressure upon the joint or lateral compression of the foot. In the mild cases it is periodic like neuralgia; in severe eases it is continuous and makes walking or even the wearing of shoes impossible. Usually the pain diminishes on removing the shoe or extending the foot forcibly. It is much more common in women than in men. It may also involve the other metatarsals. Peraire and Mally demon- strated with the .r-ray that it was due to deviation or subluxation in the metatarsophalangeal joint; the resected heads of the metatarsals showed a proliferating ostitis. T. G. Morton believed that it was due to com- 858 DISEASES OF THE ANKLE AND FOOT. pression of the branches of the external plantar nerve between the heads of the fourth and fifth metatarsal from wearing tight shoes. Narrow and short shoes unquestionably favor the occurrence of devia- tion and subluxation of the toes, for occasionally one finds the toes clawed and the pain limited to the plantar surface of the hyperextended metatarsophalangeal joints. The same pain in the metatarsals is present in beginning flat-foot. Lang and Seitz have called attention to the pain which is felt in the heads of the metatarsals after correction of a talipes equinus or varus, and which is due to pressure upon new and unaccustomed points and the consequent irritation of the periosteum. The affection is very stubborn and the treatment protracted. As a rule the treatment is limited to prescribing broad shoes, baths, gentle mas- sage, and, as suggested by Lange and Seitz, a felt sole with holes situ- ated under the painful points. We have never had occasion to resect the fourth metatarsophalangeal joint, as performed successfully by S. K. Morton in severe cases, or to resect the head of the metatarsal, as recom- mended by Peraire and Mally. [According to Whitman, 1 "the more distinctive term anterior meta- tarsalgia, a term suggested by Poulosson, of Lyons, in 1889, may be employed to include Morton's neuralgia and similar symptoms of pain and discomfort about the anterior metatarsal arch. For in many instances the cramp-like pain is referred to other points, for example, to several adjoining joints, or the discomfort caused apparently by direct pressure on the bones of the weakened arch may be more trouble- some than the irregular attacks of neuralgic pain." The condition is more commonly met with after the thirtieth year, in private than in hospital practice, and not infrequently the patients are of a nervous type. The significance of anterior metatarsalgia has been made more clear recently by the study of the relation of weakness of the anterior transverse metatarsal arch to the symptoms. "Attention was first called to this point by Poulosson, of Lyons, and again by Roughton, Woodruff, and others, and in a much more convincing manner by Goldthwait, 2 of Boston, in 1X94." Whitman described the anterior metatarsal arch as follows: if one examines a normal foot one notices that the two middle metatarsal bones, the second and third, are slightly longer and on a higher plane than their fellows. On the sole of the foot the arch is shown by the depression immediately to the outer side of the muscular projection of the great toe-joint. When weight is borne all the metatarsal bones are on the same plane and the arch is obliterated, but when the weight is removed the arch re-forms with a certain natural resiliency. In walking and standing the weight is balanced on the head of the third metatarsal bone, as shown by a thickening of the skin beneath its head, but the strain on the metatarsal arch is relieved somewhat by the balancing action of the muscles about the first and fifth metatarsal [' Whitman's Orthopedic Surgery, 1903. 2 Boston Medical and Surgical Journal, vol. cxxxi. p. 233.] CONTRACTURES AND DEFORMITIES OF THE TOES. 859 bones, the inner and outer supports of the arch (see page s -'!l , and by the active assistance of the toes themselves. When the arch is weak or broken down this natural resiliency is lost, and, in .some instant the centre of the forefoot is not only depressed, hut it is fixed in this abnormal attitude. In the ordinary type of depressed anterior arch the deformity may he shown by an imprint of the foot, in which the flabby tissues of the depressed arch encroach upon the clear spaee representing the longi- tudinal arch, and obliterate what Goldthwait calls the re-entering angle to the outer side of the great toe-joint, which in the normal foot indicate. the highest point of the metatarsal arch. In many instances, however, the imprint of the foot subject to Morton's neuralgia may be, to all intents, normal, and, on the other hand, depression of the metatarsal arch, one of the very common results of improper shoes, may be present, yet unaccompanied by pain or discomfort. Depression of the anterior arch, the result of the loss of the activity of the accessory supports of the arch, predisposes to pain because of abnormal pressure upon the persistently depressed articulations from beneath, and it predisposes to pain, as the writer has endeavored 1 to explain, because the metatarsophalangeal joints of an arch that is habitually depressed are exposed to the direct lateral compression of a narrow or ill-shaped shoe. Anterior metatarsalgia is, in most instances, the result of weakness or depression of the anterior metatarsal arch, as a whole or in part, and the quality of the pain corresponds fairly to the form of weakness or deformity. If, for example, the entire arch is rigidly depressed, as in certain rheumatic affections, the discomfort is likely to be caused, in great degree, by the direct pressure of the sensitive depressed meta- tarsophalangeal joints on the sole of the shoe; or, if lateral pressure is exerted as well, the discomfort or the pain may be referred to the metatarsal arch in general. If the metatarsal arch is weakened, de- pressed, and broadened, but not rigid, the discomfort is then referred, as in the preceding instance, to the centre of the arch, and this dis- comfort is increased, in some instances, by a painful callus representing abnormal pressure at this point. If one of the metatarsal bones falls below its fellows, the lateral pressure of a narrow shoe may cause neuralgic pains at this joint; but in many cases in which the anterior arch is depressed the patient makes but little complaint of pain. In certain instances, more particularly those of Morton's typical neuralgia, the foot may appear to all intents normal; in such cases it may be inferred that the sharp and characteristic pain is caused by pressure applied to the overriding fifth metatarsal bone, just as similar pain is felt if the hand is suddenly compressed while the fifth metacarpal bone is in the same position. This theory is the more probable when one considers the symptoms; for example, the sensation of something slipping or moving, the necessity for the removal of the shoe to flex [! Whitman, New York Medical Record, August 6, 189S.] 360 DISEASES OF THE ANKLE AND FOOT. and extend the toes and to compress the foot, apparently with the instinctive aim of replacing a depressed arch or a misplaced bone in the arch. It would also explain how the shoe may be the most direct of the exciting causes of the deformity, in that it compresses the forepart and throws more weight upon it by elevating the heel. If the arch is depressed or becomes depressed, or if a bone in the arch overrides another, this compression causes the symptoms. The shoe is, therefore, not only the direct cause but also the most important of the predisposing causes in compressing the toes, lifting them off the ground by its "rocker sole," and thus, by preventing their normal function, throwing additional strain and pressure upon the arch. In a large proportion of the feet that are supposed to be normal in appearance and functional ability Whitman found the toes habit- ually dorsi-flexed in a claw-like attitude, showing entire disuse of the function both as to support and progression. He attributed the greater frequency of the affection in women to the fact that they wore shoes with narrower soles and higher heels than men. The shoe also pre- disposes to habitual elevation of the fifth metatarsal bone, because this bone almost invariably overhangs the narrow sole. The fourth meta- tarsal thus becomes the outer support of the arch, and is almost always found on a lower level than the adjoining bones. This relation, together with a laxity of muscular and ligamentous support induced by injury or otherwise, may account for the location of the pain at this point in the majority of the cases. Although in certain instances a neuritis may follow direct injury, yet this assumption is not at all necessary to explain the symptoms. Nor is it likely that the peculiar distribution of the nerves at this point has any direct influence on the pain, for the nerve supply of all the joints and all the toes is practically identical. As further contributing causes Whitman notes the possible influence of inherited predisposition, weakness or direct injury of the anterior arch, weakness of the longitudinal arch, flat-foot, abnormal shortness of the tendo Achillis producing more pressure on the front of the foot, and, in connection with these causes, corns and callus beneath the depressed bones — a common occurrence. In some cases the symptoms can only be accounted for by a local neuritis; in others they are aggravated by gout or rheumatism or general debility. As mentioned, in a large proportion of the cases the patients are of a distinctly nervous type. The rational treatment, therefore, according to Whitman, consists primarily in the wearing of proper shoes (Fig. 547) with broad, thick soles, a high arch, as suggested by Gibney, to remove part of the press- ure from the heads of the metatarsals, and a low heel. Other measures to be considered are: a firm bandage about the metatarsal region, or, better, an adhesive-plaster strap; a pad beneath or slightly behind the affected joint or arch, as suggested by Poulosson and Goldthwait, preferably an oval of sole leather, with bevelled edges and about one inch by three-quarters in size and one quarter in thickness, to be fastened in the shoe after the proper bearing has been ascertained; finally, a metal brace. (Fig. 577.) The latter is more comfortable and CONTRACTURES AND DEFORMITIES OF THE TOES. 861 Fig. 577. far more efficient. It may be made of light steel (19 gauge) moulded upon a plaster cast of the foot, with the natural depressions somewhat exaggerated. If several metatarsophalangeal joints are sensitive it may be made the length of the toot and worn as a splint to prevent mo- tion for a while. Flattening of the longitudinal arch may be corrected by raising the inner border of the heel and sole, or, if pronounced, a flat- foot brace (Fig. 553) may be used, modified in front, as in (Fig. 577), to support the metatarsal arch. On the other hand, exaggerated arch or limited dorsal flexion require their appropriate treatment. If the arch is rigidly depressed, manipulation or forcible correction under anaesthesia are neces- sary before applying the brace. In acute cases, especially after injury, the foot should be rested and the arch elevated and supported by a prop- erly applied plaster bandage. In all cases the temporary measures should be followed by massage, regular exercise of the mus- cles, proper functional use of the foot and espe- cially methodical forced flexion of the toes to increase the anterior metatarsal arch. (Fig. 578.) In chronic and persistent cases the head and neck of the metatarsal are resected, as employed uiation. (Whitman.) by Morton. Removal of a sensitive callus beneath the arch may be necessary in some cases and, in connection with proper shoes, may be effectual, A brace for anterior meta- tarsalgia. A indicates a point beneath the fourth meta- tarsophalangeal articulation, which is elevated in order to support the depressed artic- FlG. 578. Exercise for the weakened metatarsal arch. (Whitman.) but, as a rule, a cure is possible only by overcoming the common cause of the callus, namely, the habitual depression of one or more of the 862 DISEASES OF THE ANKLE AND FOOT. metatarsophalangeal articulations, by supporting the arch and strengthen- ing its natural supports in the manner already described. The general condition is to he regarded: local applications, electricity and the like may he of benefit in special cases.] DISEASES OF THE VESSELS AND NERVES OF THE FOOT. Aneurism in the Foot. — Aneurism is rare in the foot. It usually affects the dorsalis pedis artery, and is generally traumatic. In 1889 Chauvel could only collect 20 cases of this sort. Plantar aneurism is very rare, and arteriovenous aneurisms have hardly ever been seen. There is usually no disturbance until the aneurism is quite large. It may finally erode the bones and joints and entirely disable the foot. The sac and surrounding tissues become inflamed rather frequently. Diagnosis. — The diagnosis of aneurism on the dorsum is not difficult, on account of its superficial position, unless it is filled with clots and without distinct pulsation or unless a phlegmonous inflammation exists in the surrounding tissues. In the latter case it may be confused with abscess. In the sole the diagnosis is more difficult. If the sac is inflamed, it is even more liable to be confused with abscess. Treatment. — Treatment by means of direct or indirect pressure or mere ligation of the artery is rather uncertain. The artery should be ligated above and below and the sac opened and obliterated or excised. This is done easily on the dorsum and without much difficulty in the sole. (See Popliteal Aneurism.) (For phlebectasia in the foot see section on Varicose Veins.) Gangrene of the Foot. — The foot is the favorite site of the various forms of spontaneous gangrene. Senile Gangrene. — The most common causes are the senile changes in the heart and vessels, namely, arteriosclerosis. In some cases symptoms of impoverished circulation have existed for a long time previously; coolness, numbness, pains of a rheumatic or neuralgic character. In others these prodromal symptoms are absent, and, without apparent cause, a small brownish gangrenous spot appears in the skin of the toe and gradually extends and involves one or more toes. Demarcation often takes place at this point, but more frequently the gangrene is attended with inflammatory symptoms spreading over the foot. The inflamed parts are very painful, bluish- red, and oedematous. Gradually this bluish-redness becomes livid and then black, like the gangrenous parts; at first this is chiefly con- fined to the toes. This form is apt to follow slight, often invisible injuries, frostbites, application of strong carbolic acid, etc. The slight injuries are frequently inflicted in cutting the nails or corns, etc., to relieve the prodromal pain which is attributed by the patient to the pressure of the nail or corn. If the gangrene is inflammatory —moist gangrene — from the outset or a dry gangrene becomes infected, the process is apt to spread more rapidly over the foot and leg. The DISEASES OF THE VESSELS AND NERVES OF THE FOOT, si;:; gangrenous parts are moist and putrid; phlegmon and lymphangitis may spread up the liml>, accompanied by rather high fever. Diminished heart action and atheromatous changes in the vessels are unquestionably the causes of senile gangrene. Bui the gangrene may develop in various ways. Often a marantic thrombosis, beginning in the capillaries and smaller vessels of the mosl distal parts of the extremity and gradually spreading, is the immediate cause. Naturally it occurs mosl easily after injuries and inflammations. Multiple thrombosis of the larger vessels has also been found as the result of arteriosclerosis and regarded as the cause. Heidenhain assumes that this is more apt to produce dry gangrene. It is still a matter of question (Landow) whether gangrene inevitably follows thrombosis of one or more of the larger vessels and so frequently (according to Heidenhain, in over 50 per cent, of the cases). Fig. 579. Senile gangrene of foot. (Solley.) Presenile Gangrene. — The term " presenile gangrene" has recently been applied to a form occurring in younger persons as the result of vascular changes. It occurs between the twentieth and fiftieth year; when seen previous to the twentieth year it is termed infantile or juvenile gangrene. The symptoms are often characteristic. While resting the patient feels perfectly well, but after walking for a certain length of time sensory, motor, and vasomotor disturbances develop in the leg, and especially in the foot, in the form of paresthesias, itching, tingling, cyanosis, cold- ness, numbness, and weakness, which disappear after resting but recur on walking, so that the patient has to rest at intervals. The term "intermittent limp" has been applied to this phenomenon. (Charcot, Eib, Goldflam.) In the early stages the pulse in the arteries of the foot is small or absent, as evidence of the already existing arteritis. Many of the patients become morphine subjects on account of the intense pain. A gangrenous ulcer — moist gangrene — develops from a 864 DISEASES OF THE ANKLE AND FOOT. small wound or without apparent cause and spreads, accompanied by severe pain. The changes found in the vessels are extensive obliteration of the arteries and thickening of the intima of the veins. The process was regarded by v. Winiwarter and Billroth as an obliterating or hyperplastic endarteritis, beginning in the large vessels of the leg and spreading downward; by Weiss as the result of thrombosis due to endarteritis. The closure of the vessel above diminishes the blood-supply to the still open distal portions of the artery, thus altering the relation between the lumen of the vessel and the amount of blood. This misrelation gives rise, according to Thoma, to a compensatory narrowing of the lumen, an endarteritis with contraction of the media and growth of the intima. In this way Weiss explains the fact that thickening is present in the intima of the peripheral and only partially closed smaller vessels. According to Weiss, " the gangrene is ultimately due to the usual sclerotic changes in the vessels, only that here the sclerosis gave rise to the gan- grene not directly, but indirectly through the thrombosis." The origin was therefore the same as in many cases of senile gangrene, the only difference being that in youthful, better-nourished individuals the col- lateral circulation was sufficient to retard the spreading of the gangrene. Borchard accepted v. Winiwarter's view, but more recent investigators (Bunge, Wulff, Matanowitsch) side with Zoege v. Manteuffel and Weiss. Bunge regards presenile gangrene as the result of premature arterio- sclerosis, which usually produces multiple, rarely single, stenoses, and is very apt to develop at the giving-off points of the collaterals. The thickening of the muscularis, narrowing of the lumen of the vessels, and the relatively slight growth of the intima found by many observers would indicate (Wulff) that the gangrene in many cases is due primarily to abnormal vasomotor constriction, secondarily to changes in the vessels analogous to those in Raynaud's angiospastic gangrene. The causes of early degeneration of the vessels are frequently the action of cold, abuse of alcohol and nicotine, and syphilis. Diabetic Gangrene. — Diabetic gangrene, although known for a long while and studied more closely after the publications of Marchal de Calvi and Griesino-er, has onlv recentlv claimed the attention of German surgeons since W. Roser's well-known work. Its frequency is due to two circumstances: the great susceptibility of diabetic subjects to purulent and septic infections and their sequela?, carbuncle, phlegmon, etc., and the very early appearance of arteriosclerosis in diabetes. Diabetic gangrene occurs not only in older subjects with impaired vitality, but also in younger, apparently healthy individuals. It is rare before the thirty-fifth year. The age, together with the fact that arteriosclerosis is met with in the majority of cases of diabetes, even in relatively young subjects, show the significance of vascular degeneration. In the cases of diabetes associated with arteriosclerosis diabetic gangrene would there- fore be angiosclerotic, in a certain sense an early senile gangrene. The susceptibility of diabetic tissues to severe traumatic infections and necrotic inflammations gives diabetic gangrene a peculiar character; DISEASES OF THE VESSELS AND NERVES OF THE FOOT. gQ§ gangrene of the foot and leg is a frequent occurrence in diabetic sub- jects as the result of phlegmonous inflammation in the absence of any great amount of arteriosclerosis. It is for this reason that the process is commonly a moist gangrene, often phlegmonous, developing more rapidly than the senile form, and with less tendency to demarcation and spontaneous recovery. Frostbite Gangrene. — Frostbite gangrene does not generally come under observation until it has existed for several days. The foot and often the leg are greatly swollen, the distal parts cold, bluish-red, and usually anaesthetic, but still very painful. -The skin is very tense and the epidermis raised by wheals at various points. Gangrene develops rapidly, and its extent cannot be foreseen. If improperly treated, it very often becomes moist, putrid, and accompanied by phlegmon, which spreads the gangrene; less frequently the parts mummify and are cast off spontaneously. Embolic Gangrene. — Gangrene due to embolism of the main arterial trunks, chiefly the femoral or popliteal, is more rare. The embolism is usually the result of endocarditis. Embolism or thrombosis may occur during or after a severe infectious disease (typhoid, measles, scarlet fever, pneumonia, influenza) and produce gangrene of the leg in the absence of any endocarditis. Contusion of the femoral artery has been followed by thrombosis and gangrene of the leg. Cases of presumably secondary thrombosis or embolism of one lower extremity have followed severe contusion of the thorax or abdomen ; in several cases the gangrene followed in eight or nine days after the injury. In a number of instances in children and adults a circumscribed patch of endarteritis of the femoral artery, of syphilitic or unknown origin, has given rise to gangrene of the foot. Syphilitic arteritis has been repeatedly followed by symmetrical gangrene of the feet, hands, or other parts of the body. Some of the cases were looked upon as being Raynaud's angiospastic gangrene, because the prodromal symptoms — temporary suspension of circulation, etc. — were similar. The author believes that these syphilitic cases and the angiosclerotic cases in young subjects, in which circulatory disturbances occasionally appear before the gangrene, and in which the gangrene can be symmetrical, should not be classified as yet with the etiologically obscure Raynaud's gangrene'. Raynaud's Gangrene. — Raynaud's gangrene is usually ushered in by general nervous and mental disturbances. The feet become paresthetic, sometimes cold and pale, or cyanotic; the attacks vary in intensity and duration, and are occasionally accompanied by severe pain. The symptoms may persist unchanged for years or decades, w r ith remissions and improvement, but gangrene follows in severe cases. Raynaud refers the process to a spastic contraction of the vessels, due to altered inner- vation of the vessels of central origin. The author believes with Oppen- heim that in some instances it may be an independent disease, but in others it is merely a symptom observed in other nervous diseases (hysteria, tabes, epilepsy, syringomyelia, etc.). Gangrene due to ergotism is now a great rarity. Vol. III.— 55 866 DISEASES OF THE ANKLE AND FOOT. Treatment. — In all these varieties the essential is to avoid infection of the dry gangrene and to transform the moist into the dry form. The limb should therefore be sterilized and wrapped in dry aseptic gauze. Moist gangrene should be disinfected and deodorized with powder or wet dressings of boric acid, chlorine-water, or aluminum acetate. Stronger and poisonous remedies should not be used as they are readily absorbed. The limb should be elevated and demarcation awaited unless operation becomes necessary. Demarcation should be awaited in senile gangrene, even if the process extends slowly, as it usually stops in the foot or in the leg, and any mild lymphangitis which occurs yields promptly to appropriate treatment. The stump can then be amputated in sound tissue. Early operation is indicated if there are severe pain, rapid advance of the gangrene, marked inflammation, and loss of strength. The prognosis is then less favorable. The above applies in much the same way to diabetic gangrene. The majority of surgeons prefer to await demarcation, put the patient on an antidiabetic diet, and increase the general strength. The glycosuria decreases or disappears as the gangrene becomes limited. Separation of the stump is rarely to be expected, but the prognosis of amputation becomes more favorable if the amount of sugar can be diminished, extension of the gangrene checked, and the lymphangitis overcome. If the percentage of sugar remains high and the gangrene advances rapidly with fever and acute inflammation, the general strength diminishes rapidly. These cases are apt to be in younger subjects with a very high percentage of sugar. In older patients with a lower percentage of sugar, even with marked atheroma and a rather pronounced albuminuria, high amputation may be successful in spite of the rapidly advancing moist gangrene. The prognosis of amputation in general is bad. The diminution of sugar following amputation or demarcation can be under- stood from the fact that a temporary glycosuria is frequently seen during suppuration in non-diabetic patients. The level at which to amputate has been a much disputed question. If single toes are affected, amputation can be performed safely in the foot or low in the leg. If the gangrene extends above the ankle, some surgeons advise to always amputate in the thigh. (Heidenhain.) This generalization has met with decided opposition. (Konig, Landow.) If demarcation is distinct we may amputate according to Pirogoff or in the leg. If the process is advancing or phlegmonous, or the main arteries are sclerotic or occluded, amputation of the thigh is preferable as a rule. There seems to be no question that amputation in the leg can be successful, even when the main arteries of the leg are occluded (Landow), but it also seems venturesome to attempt it. The author considers that occlusion of the main trunks has a greater significance in senile and diabetic gangrene than that assigned to it by Landow. As far as a general rule is possible, amputation should be in fairly sound tissues; this presupposes patency of the more important arteries. Even this rule has its exceptions, for occasionally one finds the femoral closed on amputating in the thigh. NEUROPATHIC AFFECTIONS OF THE FOOT. 3^7 In the treatment of the seven- pain and the circulatory disturbances of the prodromal stage of angiosclerotic gangrene in younger subjects, Zoege v. Manteuffel warns against massage and dietetic, thermic, and mechanical measures as being injurious to the circulation, and advises rest, elevation of the limb, exercises to strengthen the heart, and warm baths. Erb recommends the prolonged use of potassium or sodium iodide. If gangrene occurs, demarcation is rarely to be expected. The rapid extension, the pain and loss of strength are all urgent indica- tions for amputation. Zoege v. Manteuffel recommends Gritti's exar- ticulation at the knee, as after amputation lower down healing is less favorable and the severe pain is apt to continue from the irritation of the nerve stumps. In frostbite gangrene demarcation should be awaited, the limb being elevated or suspended, (v. Bergmann and others.) If phlegmon occurs, it should he treated appropriately. Amputation higher up may be necessary if the phlegmonous process spreads, accompanied by high fever. The position of the cicatrix is important; if amputation is per- formed in the foot the cicatrix is very apt to become ulcerated later on account of the circulatory disturbance due to venous congestion. In the other forms of gangrene, the rules for amputation are about alike. In the cases due to embolism and thrombosis the situation of the thrombus is conclusive; in those due to syphilis and neuropathic disturbances the stump can usually be removed close to the line of demarcation. In single instances of syphilitic endarteritis gangrene has been averted by specific treatment. In general all bleeding points should be carefully ligated, the flaps should not be made too tight or too loose, and pressure in applying the dressings avoided. If the wound is clean, it may be closed partially and drained; otherwise it should be packed loosely, left open, and drained until all inflammation has subsided, then sutured secondarily or allowed to heal in by granulation. NEUROPATHIC AFFECTIONS OF THE FOOT. Perforating Ulcers of the Foot. — Perforating ulcer of the foot (mal perforant du pied of Xelaton) is a chronic, painless ulcer which is apt to invade the deeper parts, to recur, and to resist all forms of treatment. It is characterized especially by anaesthesia or analgesia which may be confined to the area about the ulcer, or occur in patches or diffusely over the entire foot. The usual seat of the ulcer is in the sole, particularly under the metatarsophalangeal joints (first and fifth toe), and under the heel, namely, the points of support of the foot. It is also found at other points in the foot, but less frequently. Very often there is at first a growth of epithelium, a hyperkeratosis, under which suppuration occurs as the result of trauma, and then perfora- tion. The suppuration may start in an accidental bursa beneath the growth. The resulting ulcer is small, with vertical, undermined edges, 868 DISEASES OF THE ANKLE AND FOOT. and surrounded by thickened epidermis; it has but little tendency to heal. It burrows into the tendon-sheaths, the joint, or the bone. Excep- tionally temporary recovery takes place spontaneously, but on account of the analgesia the ulcer is usually neglected, discharges a viscid foul pus, and leads to suppuration of the joint, necrosis of the bone, or even severe ichorous phlegmon. The course is generally very slow and extends over years. In the majority of cases the condition is due to nervous disturbances, and is almost always accompanied by abnormalities of sensibility, anaesthesia or analgesia at or near the ulcer, and frequently by neuro- trophic changes in the nails, skin and bones, pareses, and abnormal reflex irritability. As first demonstrated by Duplay and Morat, and confirmed later by other authors (v. Bruns, H. Fischer, and others), it is a neuroparalytic ulcer of central or peripheral origin, the most frequent causes being tabes, general paralysis, syringomyelia, injuries and dis- eases of the spine with secondary lesions of the cord, and spina bifida; the somewhat less frequent peripheral causes are trauma, tumors of the nerves and all forms of neuritis. Inflammatory changes— hyperplastic neuritis — are often found in the nerves. To the author the term mal perforant does not imply necessarily the existence of inflammatory changes in the nerves about the ulcer. Such changes may be absent in cases in which the entire clinical picture is that of a typical neuroparalytic ulcer, if the affection is of central origin. Then again it is in the se very cases of central origin that they are found so often. The changes in the peripheral nerves are most probably due to irritation, traumatic or inflammatory, produced by the ulcer. Neuritis occurs with various constitutional diseases, such as alcohol- ism and diabetes. The neuritis associated with diabetes is apparently a frequent cause of perforating ulcer, as noted by Kirmisson and Jaennel. The ulcer may be coexistent with diabetic gangrene or suppuration, but is to be distinguished from them. It also occurs in leprosy, but here again it is due to disease of the nerves found in leprosy (lepra anses- thetica), not to the leprosy itself. The term mal perforant should be limited to ulcers of nervous origin, as ulcers equally stubborn and painless occur in the foot, but from entirely different causes, for example, syphilitic ulcers, carcinoma, localized gangrene, and the ulcers due to atheroma, or suppuration of bursa? under callosities. Malum perforans pedis is therefore a neuroparalytic ulcer. Local trauma is undoubtedly an important factor in the etiology — that is, the exciting cause — of an ulcer associated with a nervous disease; but the latter is always the predisposing cause. The form and extent of the ulcer are determined by the repeated insults to which it is exposed by reason of the existing analgesia. Treatment. — The treatment is both general and local: Protection from injury by means of absolute rest, and from infection by covering with antiseptic or aseptic dressing; removal of the thickened edges of the ulcer, resection of necrosed bone or a suppurating joint; general NEUROPATHIC AFFECTIONS OF THE FOOT. 869 treatment of the primary disease. Little improvement is obtained by genera] treatment in the majority of eases. The ulcer may heal, but others are very apt to break out in other places unless the primary dis- ease is cured. Ulcers have been even known to appear on the stump after amputation. Recently Sick has successfully overcome the affection by stretching the posterior tibial nerve behind the inner malleolus or the internal and external plantar nerves, as recommended by Chipault, in addition to treating the ulcer locally (asepsis, curetting, etc.). Sensory and Trophic Disturbances of the Foot. — Sensory and trophic disturbances due to syringomyelia are observed much less fre- quently in the feet than in the hands. Occasionally cases are seen giv- ing Morvan's symptom-complex; wheals, panaritia with necrosis of the phalanges, mal perforant, spontaneous gangrene, etc. Trophic disturb- ances are found more frequently associated with tabes, such as dys- trophy of the skin and nails, hyperidrosis, local fever, mal perforant, etc. Even more important are the arthropathies which are found so very fre- quently with tabes, and rarely with syringomyelia, progressive paralysis, etc. In tabes the joints of the toes may become swollen and distended by effusion, the ligaments relaxed, and the bones deformed; but such primary affections of the joint are not common. Kredel was able to collect only 10 cases. We saw one case of multiple ataxic arthropathy in which several joints of the toes were involved. The metatarsophal- angeal joints, especially the first, are apparently the ones most commonly affected. Entire phalanges may be absorbed without suppuration and give rise to deformation analogous to the process observed in a few instances in the fingers, but usually the diseased joints suppurate and the bones become necrotic and are cast off. Tabetic disease of the tarsus, which was first described by Charcot and Fere (pied tabetique), gives an almost typical picture. The process is very apt to begin before, as well as in, the ataxic stage, and develop insidiously and slowly; less frequently it develops rapidly after injury. In some instances it produces no discomfort, in others there are dull pains, a sense of heaviness, and numbness or formication in the foot. Deformation takes place in the course of several weeks or months. The dorsum is thickened. In most of the cases the swelling is even more marked on the inner border of the foot, at the scaphoid and astragalus. The sole is flattened. The foot may be abducted, especially the front part (tabetic talipes valgus), and everted, or adducted and inverted, and also extended (varus and equino varus). The affection may be unilateral or bilateral. According to the amount of deformation present, one finds abnormal mobility, crepitus, etc. Anatomically the changes found were those of a high-grade arthritis deformans; defects in the cartilages, erosion of the tarsal bones, destruction and obliteration of the old joints, and the formation of new joint-surfaces. The bones were greatly altered, either fractured or worn off. The .r-ray showed the existence of an osteoporosis similar to that found with bony tumors; the contour of the bones was obliterated, the trabecular had dis- appeared. 870 DISEASES OF THE ANKLE AND FOOT. Tabetic arthropathy of the tibiotarscd joint is not rare; Kredel collected 25 cases. The joint is enlarged by effusion or by thickening of the epiphysis of the tibia and fibula, and in the severe cases is usually loose. The position of the foot varies, but is usually a high-grade talipes varus. The astragalus is often fragmented and dislocated, the fragments lying as free bodies in the joint. (Rotter, and others.) The articular ends of the tibia and fibula are widened and partly united to each other by growth of the periosteum. Fractures of the malleoli and pseudarthroses are also found. The enlargement of the bones may suggest a bony tumor previous to the examination of the nervous system. Treatment.— In the case of all these tabetic diseases of the bones and joints conservatism is the rule; the foot is immobilized, more particu- larly after fractures of the malleoli, sudden exacerbations, effusions or inflammations, and protected in a splint or apparatus against injury and, if possible, further deformation. Resection of the joint is without benefit (compare Schoonheid's compilation of operative results) and therefore inadvisable. If perforation of the joint and suppuration follow, amputation is the best treatment. Deformed and troublesome toes should also be amputated. Small bones which have become necrotic as the result of perforating ulcers can be excised. By careful treat- ment it is often possible to effect an improvement, a gain, however, which is not infrequently temporary. TUMORS IN THE FOOT. Numerous tumors occur in the foot, few of which, however, acquire any peculiarity from their situation. Benign Neoplasms. — Single instances of fibroma, neuroma, keloid, etc., have been recorded. Lipoma is somewhat more common, is most apt to be situated in the sole, and may be congenital. (See Congenital Hypertrophy. ) Simple angioma and telangiectasis show no peculiarities in children. Large cavernous angioma and phlebarteriectasis (cirsoid aneurism) are rare. The symptoms and treatment of the two latter diseases are the same as those of the corresponding tumors in the hand, where they are more frequent. Chondroma is by no means rare in the foot, and, as in the hand, develops chiefly in the medulla of the phalanges and metatarsals and is apt to be multiple. It is found less frequently in the tarsal bones, for example, the calcaneum. On account of its relative benignancy one may attempt to scrape it out at first, or to resect the bones, but usually the tumor has to be removed by amputation. Osteoma has been seen at various points on the foot and rather fre- quently in the heel. In the latter position it occasionally starts from the calcaneum, or it may be situated in the soft parts. Of the exostoses from the bones of the foot, the most frequent and TUMORS IX THE FOOT 871 most interesting are the subungual growths in the toes which were first accurately described by Dupuytren. They are more common in the great toe than in the others and more often situated under the nail than at the edge. They are seen almost entirely in young individuals. The etiology of this form of exostosis is still a matter of discussion. Many authors (Virchow) believe that, although the tumor is referable in general to the period of evolution, it should be classified with the peri- osteal growths due to irritation; others attribute it to exuberant growth of the cartilage in the transition stage. The fact is interesting that these o O o so-called exostoses are sometimes found separated from the bone by fibrous tissue, namely, that they are periosteal osteomata, occasionally containing cartilage. The tumor is usually small, composed of thick or porous bone, covered with thick periosteum or a layer of cartilage, and sometimes contains cartilage. It may develop from connective tissue, periosteum, or cartilage. It grows slowly, and gradually lifts and loosens the nail. Sometimes it is removed partially by the patient to relieve the pain caused by the pressure of the shoe. The diagnosis is often difficult at the outset. The nail should be extracted and the growth removed. The so-called traumatic epithelial cysts sometimes appear in the sole after injury as in the hand, and are easily cured by excision. Warts and larger flat papillomata may be single or multiple and by reason of their situation cause great annoyance and pain. They can be cauterized, curetted, or excised. Fibroma and leiomyoma ( ?) have also been reported. Malignant Neoplasms. — Sarcoma has been seen in a few instances as a congenital tumor. Sarcoma of the skin (sarcoma molluscum) is apt to develop, as in other parts of the body, from congenital warts and nsevi, and may or may not contain pigment, Sarcoma originating in the fascia, ligaments, and tendon-sheaths is often mistaken at the outset for tuberculous abscesses, etc., and incised. Subungual sarcoma can be confused with the corresponding form of exostosis; it may develop rapidly, or be incapsulated and grow slowly. If situated on the edge of the nail, it can be mistaken at the outset for an ingrowing nail. Under the name of calcified endothelioma Perthes describes two tumors situ- ated symmetrically under the skin of the soles, which were similar in structure to endothelioma in other parts of the body. Osteosarcoma is not rare, and is most frequently met with in the metatarsals and phalanges. Of the tarsals, the calcaneum is most often affected, in accordance with its apparent predisposition to become the seat of tumors. The growth may develop from an enchondroma (Borchardt); it is not infrequently confused with other conditions, with chronic osteomyelitis or tuberculosis. The absence of symptoms of inflammation in the soft parts speaks fcr the existence of a tumor, although chronic osteomyelitis and tuberculosis may exist for a long time without giving such symptoms. The a>ray shows the presence of a peculiar, uniform transparency in the structure of the bone, which is absent in inflammatory processes, and only seen otherwise in tabes. 872 DISEASES OF THE ANKLE AND FOOT. A peculiar disease of the skin, which is most apt to appear in the leg and foot, has been described by Kobner under the name of multiple pigmented sarcoma or hemorrhagic sarcoma. The peculiarly benign course and the circumstance that the growth of the nodules is limited and capable of receding spontaneously, make it probable that the process is a chronic infectious disease. The treatment of sarcoma of the foot is not in any way exceptional. Subungual angiosarcoma is readily excised after removing the nail. Small tumors in the soft parts can also be excised. Larger tumors in the soft parts and osteosarcomata demand partial or complete amputa- tion of the foot on account of the liability of recurrence. Two cases of sarcoma of the calcaneum are known in which excision of the calcaneum and removal of the tumor with chisel and spoon were followed by cure lasting for a long period of time. Carcinoma of the foot is usually of the flat epithelial variety, and is apt to develop from old cicatrices due to trauma, burns, frostbites (v. Berg- mann), or ulcers, or from chronically irritated spots, such as callosities, corns, etc. It develops less frequently from hard, horny warts. The diagnosis of carcinoma of the skin is not difficult unless the growth is situated in the sole. There it may be confused with benign papilloma if small and not ulcerated. Carcinoma can be distinguished from perforating ulcer in this situation by the fact that the former is usually very painful, v. Yolkmann reports a case of pigmented epithelial carcinoma of the heel and sole; this form is relatively favorable if excised radically or removed by amputation. Soft myeloid carcinoma is more rare. It is most apt to develop from congenital moles or those acquired in early childhood, but also occurs independently. The prognosis of soft carcinoma, particularly when derived from a congenital mole, is very unfavorable, as it becomes rapidly metastatic. CHAPTER XXXIX. OPERATIONS ON THE FOOT AND ITS JOINTS. AMPUTATION AT THE ANKLE. Syme's Amputation. — Starting at the tip of the external malleolus the incision is carried straight across the sole to a corresponding point on the other side, \ inch below the tip of the internal malleolus; the dissection is then carried down to the bone. The heel is dissected back close to the bone, the tendo Achillis divided at its insertion, the tissues Fig. 580. 1. Incision for amputation of the great toe. 2. Pirogoff's incision for amputation of the foot. (v. Bergmann.) Fig. 581. Line of division of bones according to Pirogoff. (v. Bergmann.) on the dorsum divided straight across between the ends of the first incision, the astragalus disarticulated, the end of the tibia and fibula freed and sawed off straight across just above the joint, and the anterior and posterior arteries ligated. The heel-flap is turned forward, sutured, and drains inserted at the sides. Pirogoff's Osteoplastic Amputation (Figs. 580 and 581). — With the foot at a right angle to the leg the incision is carried down to the bone, ( 873) 874 OPERATIONS ON THE FOOT AND ITS JOINTS. beginning a finger's breadth above the tip of the internal malleolus, and running down and across the sole toward a corresponding incision from the external malleolus. With the foot extended the ends of the incision are united by one across the dorsum; the ankle-joint is then opened, the foot disarticulated backward, the calcaneum sawed through from above, and close behind the joint, obliquely downward and forward; the malleoli are then freed and sawed off straight across just above the Fig. 582. Stump from Pirogoff's amputation. (Hartley.) joint. The anterior and posterior arteries are ligated, the heel-flap turned forward, the bones sutured together with catgut, and the dorsal flexor tendons sutured to the front of the heel-flap. The turns of the dressing should be applied from behind forward to hold the bone surfaces in contact. Sedillot, Gunther, and Busch suggest making the plantar incision and the division of the calcaneum more obliquely forward and down- Fig. 583. G'inther's modification of Pirogoff's amputation. ward from above in order to facilitate coaptation of the bone stumps in case of resistance at the back of the heel; also to make the dorsal incision more obliquely forward and to saw through the malleoli in a corre- spondingly oblique direction. (Fig. 583.) Pasquier, Le Fort, and v. Esmarch saw through the calcaneum horizon- tally (Fig. 584), beginning the plantar incision f inch below the tip of AMPUTATION AT THE ANKLE. 875 the external malleolus, and continuing it in a curve, convex forward, across the sole to end U inches below and in front of the internal mal- Fig. 584 Le Fort's modification. Fig. 585. *s Fig. 5S6. S ■^ : Tauber's incision for osteoplastic amputation. leolus; the dorsal incision connects these points in a curve, convex for- ward, over Chopart's joint, v. Bruns saws through the calcaneum in a 876 OPERATIONS ON THE FOOT AXD ITS .JOISTS. curve concave from forward backward and makes the cut through the malleoli correspondingly convex. Tauber saws through the calcaneum vertically in the anteroposterior direction and turns up the inner lateral stump. (Figs. 585 and 586.) Or the incision may be reversed and the outer half of the bone used. Rasumowsky modifies this somewhat in the case of children, in order to save the lower epiphysis of the tibia, by rounding off the bone-flap of the calcaneum and turning it up between the malleoli; the dorsal flexor tendons are sutured to the flap. Ktister in one instance made a large plantar and small dorsal flap and fitted the entire calcaneum between the malleoli. The results of Pirogoff's method and its modification are usually excellent; as a rule the bone surfaces unite solidly in time — often not until after the patient is about — and the stump becomes resistant and painless. If union remains insufficiently firm, the surfaces can be freshened up and sutured or nailed. Osteoporosis is not a contra- Fig. 5S7. Perrin and Cham-el's incision for subastragaloid amputation. (Roux de Brignoles.) indication to the operation, as the bones become more solid after the leg is used. In children, in order to save the epiphyseal line of the tibia, the operation may be confined to removing the malleoli. It is not advisable in general, however, to scrape out and leave a diseased calcaneum. Although a prothesis is not indispensable, a shoe may- be worn having two side braces, extending to the knee, attached to it, and a strip of spring metal in the front part of the shoe to give elasticity. Subastragaloid Amputation. — This method of removing all of the foot except the astragalus was first proposed by Lignerolles (1839) and Yelpeau, performed for the first time by Traill (cf. Roux de Brig- noles) and Textor (1841), and by the French generally named after Malgaigne. The ankle-joint and astragalus have to be intact, and, in spite of the calcaneum and the rest of the foot being diseased, sufficient healthy material for the flap has to be secured from the back part of the foot. Chopart's amputation would, therefore, be preferable if the calcaneum were healthy, and if the latter condition obtained; but if the AMPl TATION AT 77/ A' MEDIOTABSAL JOINT. 877 hone could not be covered in properly, the author would prefer Pirogoff's method. This operation, which is employed mainly by the French, is therefore seldom indicated. Textor proceeds as in Chopart's amputation, by making a small dorsal flap, the ends of which join a transverse plantar incision al I lie level of the mediotarsal joint. To facilitate the removal of the calcaneum Gtinther makes a horizontal incision backward from the outer angle of the incisions which corresponds to the calcaneo-astragaloid joint. Verneuil makes an oval incision, Perrin a racquet incision. (Fig. AST.) The head of the astragalus is sawed off if sufficient skin cannot be obtained. Hancock leaves the tuberosity of the calcaneum and turns it up against the astragalus. Tripier saves the lower half of the calcaneum. (Fig. 588.) Mal- gaigne modifies Tripier's incision by making a small outer and a large Fig. 588. Tripier's subastragaloid amputation. inner flap. The incision begins above the tuberosity of the calcaneum, divides the tendo Achillis, curves forward under the external malleolus to the middle of the cuboid, then continues over the dorsum at the anterior margin of the scaphoid and down to the middle of the sole,, and finally directly backward to the starting-point, v. Volkmann makes a large inner flap; Farabeuf large inner and plantar flaps. AMPUTATION AT THE MEDIOTARSAL JOINT. Chopart's Amputation (Figs. 589 and 590). — A small dorsal flap is made by means of an incision beginning at the outer border of the foot, midway between the base of the fifth metatarsal and the external malleo- lus, and curving forward over the dorsum and then backward on the inner side to the tuberosity of the scaphoid. The flap is dissected back and the tissues on the dorsum divided transversely down to the bone between the ends of the incision with the foot extended. The foot is then dis- 878 OPERATIONS ON THE FOOT AND ITS JOINTS. Fig. 589. articulated in the astragalonavicular and in the calcaneocuboid joints. A large plantar flap is then made, including the tendons and muscles. The dorsal and internal and external plantar arteries are ligated. If enough skin can be obtained, a single large plantar flap is prefer- able. To prevent the retraction and eversion (equinovalgus position) of the heel which al- most alwavs takes place, because of the trac- tion of the tendo Achillis and weighting of «• the stump, the dorsal flexor tendons can be sutured to the plantar fascia and the stump flexed in the bandage. As soon as the shoe can be w r orn, the sole can be raised in front and a side brace fastened to the shoe to pre- vent eversion. If the retraction of the heel becomes troublesome, the tendo Achillis should be divided. The operation can be modified by sawing off the anterior articular surfaces of the astragalus and calcaneum (amputatio talocalcaneo ) without opening the ankle-joint, or by disarticulating between the scaphoid and cuneiforms and sawing off the Plantar flap in chopart's ampu- cuboid transversely. This preserves the in- cation (0), and Listranc s amputa- . . .,.*',. . l ,-p, ,.,, tion (a). sertion of the tibialis anticus. Iwo modih- Fig. 590. Stump from Chopart's amputation, a, front view; 6, side view. (Stimson.) AMPUTATION OF SINGLE METATARSALS AND TOES. 879 cations suggested by Helferich, removal of the front of the calcaneum downward and backward to prevenl pressure of the front margin against the soft parts and decubitus, and arthrodesis of the ankle-joint possibly of value when the muscles of the leg are paralyzed), although not necessary, should be mentioned. AMPUTATION THROUGH THE TARSOMETATARSAL JOINTS. Lisfranc's Amputation (Fig. 589). — A Large plantar and a small dorsal, or a single large plantar flap, are formed by means of a dorsal and a plantar incision beginning at the base of the fifth metatarsal and ending on the inner side of the foot at the base of the first metatarsal. The flaps are dissected back slightly, the front of the foot depressed, the fifth metatarsal disarticulated, then the third and fourth, then the first and second, the latter while the foot is abducted. The dorsal tendons are sutured to the plantar faseia. The slight equinovalgus position resulting may be overcome by raising the front of the shoe. AMPUTATION THROUGH THE METATARSALS. Sharp's Amputation. — The operation is analogous to Lisfranc's amputation, but is preferable to it as it gives a longer support. It is rarely indicated except for injuries or frostbite of the toes with involvement of part of the skin of the dorsum. AMPUTATION OF SINGLE METATARSALS AND TOES Amputation of a single toe with its metatarsal is rarely indicated and is a questionable procedure on account of the resulting functional dis- turbance. This applies particularly to the first toe. Its function may be assumed by the second toe, but the foot is very liable to become abducted and everted and make walking difficult. If a flat-foot position already exists, its removal is less troublesome. Amputation of one, or even two, of the middle metatarsals, or of the fifth, is even less serious. If the two inner metatarsals or three of the others have to be sacrificed, it is better to amputate all transversely through the bones, or at Lisfranc's joint. The first or fifth metatarsal and its toe are usually amputated through an oval (racquet) incision, the longitudinal incision being made midway between the dorsum and side of the toe to prevent pressure upon the scar, analogous to the method for the thumb. The oval incision is also the best for one or more of the other metatarsals. In removing two metatarsals care should be exercised to have sufficient skin on the dorsum, also making a transverse incision over the tarsometatarsal joints to gain access to the latter. When the fourth and fifth are con- cerned the longitudinal dorsal incision is made over the fourth and curved out sharply or gradually at the base of the metatarsus to reach the joint of the fifth. 880 OPERATIONS OX THE FOOT AND ITS JOINTS. AMPUTATION OF THE TOES. Amputation of all the toes in the metatarsophalangeal joints can be done by the small dorsal and large plantar flap method. Two lateral longitudinal incisions are carried forward on the first and fifth toes to the level of the commissures. The toes are exarticulated through a transverse dorsal incision at the level of the commissures and a large plantar flap formed. Single toes can be amputated by the oval method. In amputating the large toe a flap taken from the inner and plantar surfaces is preferable in order to bring the scar between the first and second toes, and not on the dorsum or front, where it is exposed to pressure. For amputation or exarticulation of the phalanges a large plantar flap is preferable. RESECTION OF THE TIBIOTARSAL JOINT. Typica. resection of the ankle-joint was first performed by Moreau in 1792, but was not generally adopted until after B. v. Langenbeck hail demonstrated its value in the Danish war of 1864. Langenbeck's Method. — Langenbeck's method of making two lat- eral longitudinal incisions is similar to that of Moreau and Bonrgery's modification of the same: the outer incision, 2 to 3 inches long, is car- ried along the posterior border of the fibula to a finger's breadth below the tip of the malleolus. Hiiter adds a second incision extending h inch upward and forward from the lower end of the first incision along the front border of the fibula. The periosteum is lifted off from the bone, the joint between the tibia and fibula opened, the fibula sawed through with a chain or keyhole saw, and the lower portion removed. The incision on the inner side is made in the same manner, the tibia being sawed off at the same level as the fibula after dividing the deltoid ligament and everting the foot. The foot is then disarticulated outward and the astragalus sawed through or removed as indicated. For re- section of the lower end of the tibia alone v. Langenbeck makes the usual longitudinal incision, and adds a curved incision, convex down- ward, encircling the tip of the malleolus (anchor incision). Hiiter used this anchor incision for total resection. The subsequent functional result depends upon the stability of the new joint and the position of the foot. A firm nearthrosis with slight mobility is possibly most desirable, yet complete ankylosis is nearly as useful, for the foot-joints acquire a compensatory mobility and restore the elasticity of the gait to a certain extent. An unstable near- throsis or actual loose-joint renders the foot more or less useless; hence the importance of not attempting to restore any great amount of mobility by methodical exercises. After subperiosteal resection for trauma the new bone formation is generally abundant and consolidation rapid. On the other hand, resection for tuberculosis is more apt to give a flabby nearthrosis, although the healing process often advances slowly RESECTION <>F THE TIBIOTARSAL JOINT. 881 but steadily, and many a loose joint finally acquires the necessary stability, provided that it is protected properly and for a sufficient length of time by a good fixation splint. The position of the foot is equally important. It should be at a right angle to the le< RESECTION OF THE TIBIOTABSAL JOINT. 883 from the fibula and calcaneum, the astragalonavicular joint opened, and the interosseous ligaments divided; the deltoid ligament is divided and the astragalus exposed and extracted. Vogt's Method. -P. Vogt recommends to always remove the astrag- alus. Like Oilier he makes a long anterior and a transverse lateral incision: the anterior incision, in adults 4 inches long, passes down over the ankle-joint from between the tibia and fibula to Chopart's joint. The tendons of the extensor longus digitorum are drawn to the inner side, the extensor brevis is incised and drawn outward. The capsule is then divided in its entire extent, the neck and head of the astragalus exposed, and the astragalonavicular ligament divided. After Fig. 594. Trillion of peronei. External malleolus. Caput tal Trochlearis. Kocher's resection. Istragalonavicular joint. Tnnloii of peronei. Internal malleolus. thus exposing the front and outer part of the astragalus, the transverse incision is made outward to below the tip of the external malleolus. The soft parts are incised in layers down to the astragalus, the foot is strongly inverted, the external lateral ligament divided and the ligaments in the sinus tarsi divided with the knife or chisel. The head of the astragalus is seized with the bone forceps, and the bone is twisted outward so that the ligaments on the inner side can be lifted off with a broad chisel. After dividing the ligaments behind and removing the astragalus, the entire joint can be inspected. Kocher's Method. — Kocher, Albanese, and Lauenstein use an outer curved incision (Fig. 504), beginning 4 to 5 inches above the tip of the malleolus, running down behind the fibula and forward under the 884 OPERATIONS ON THE FOOT AND ITS JOINTS. malleolus at the level of the calcaneo-astragaloid joint to the end at the peroneus tertius. The lesser saphenous vein and external saphenous nerve are behind the incision. The sheaths of the peronei are exposed and opened lengthwise. The periosteum is lifted from the outer and under surface of the malleolus and the joint opened in front. The capsule is dissected off from the external surface of the astragalus to the fibula and the ligaments divided; the capsule and periosteum are separated from the tibia in front and behind, the tendon-sheaths of the peronei being left attached to the periosteum; the foot is dislocated inward. The internal lateral ligament is not divided unless necessary. Anterior Transverse Incision. — Heyfelder, Sediliot, Hiiter, and many others recommend an anterior transverse incision between the malleoli. The anterior tibial artery is double ligated, the peroneal nerve and tendons are transfixed with catgut before being divided, in order to be sutured later; the joint is then opened transversely. If the incision is curved forward to form an anterior flap, Lisfranc's joint is also exposed, and if necessary v. Bruns' tibiocalcaneal resec- tion can be made. (See page 886.) With this anterior flap incision we have kept the wound open for a long while and still preserved some extensor power of the toes. To open the joint from behind or below (posterior tarsectomy), C. Textor makes a posterior transverse incision dividing the tendo Achillis. F. Busch makes an inferior stirrup-shaped transverse incision: Beginning at the external malleolus the incision crosses the sole, curving slightly backward, and ends at the internal malleolus. The tendons, vessels, and nerves are lifted en masse out of the grooves behind the malleoli and drawn upward. The calcaneum is divided transversely and obliquely upward and backward to the posterior margin of the calcaneo-astragaloid joint, the posterior part of the capsule incised, and the joint exposed by separating the fragments. The latter are sutured together with silver wire later. Ssabanejew makes a posterior triangu- lar flap with the angles of the base at the malleoli and the apex at the insertion of the tendo Achillis. The tuberosity of the calcaneum is sawed off and turned up together with the soft parts and later fastened back in place with ivory pegs. Bogdanik's modification is similar: The incision connecting the tip of the malleoli crosses the heel ^ inch above the sole, the calcaneum is sawed through transversely up to the calcaneo-astragaloid joint, the contents of the joint or the astragalus are removed, and the calcaneum sutured. All three methods have the disadvantage of possible malunion in the event of suppuration. RESECTION AND EXCISION OF THE CALCANEUM. Rigaud makes a horizontal U-shaped incision running forward at both sides of the bone and dividing the tendo Achillis at its insertion. The plantar flap is dissected off together with the periosteum. The upper flap includes the periosteum, the tendon-sheaths at the sides behind the malleoli, and the insertion of the tendo Achillis. After opening RESECTION AND EXCISION OF TILE ASTRAGALUS. 885 the calcaneocuboid and calcaneo-astragaloid joints, the ligaments in the sinus tarsi can be divided and the bones extracted. It would be preferable when possible to preserve the connection between the tendo Achillis and periosteum on the plantar surface of the calcaneum. Oilier makes an external angular incision, the vertical limb beginning 1 inch above the level of the tip of the external malleolus at the outer border of the tendo Achillis and running down under the heel, the other arm running from this point along the outer border of the foot to the base of the fifth metatarsal and then turning slightly upward. The outer Hap is lifted subperiosteally from the bone leaving the tendo Achillis still attached to the periosteum of the plantar surface. The inner flap can be peeled oil' in the same way, and the skin, together with the tendo Achillis and periosteum, drawn forward and inward. The calcaneocuboid joint can then be opened, and with a thin bladed knife, the calcaneo-astragaloid joint. While the bone is pulled downward with the bone forceps the interosseous ligaments are divided and the separation of the soft parts on the inner surface completed. In the existence of marked swelling the last step is facilitated by an incision on the inner side. Complete loss of the calcaneum disables the foot considerably, although not entirely; the arch of the foot is destroyed; eversion and inversion, and more especially plantar flexion, are impaired; the elasticity of the foot is wanting, so that the gait is heavy. This can be improved some- what by a support in the heel of the shoe. As a rule, the results are much better if the periosteum can be preserved, for from this a partial regeneration of the bone takes place. This is particularly true in youthful individuals, and especially after osteomyelitic necrosis. The value of preserving the tendo Achillis and the posterior epiphysis has been mentioned. It is equally important to preserve the anterior process, in order to avoid opening the anterior joint of the calcaneum, if possible. RESECTION AND EXCISION OF THE ASTRAGALUS. The astragalus is excised preferably through an external incision, as made by Vogt and Oilier. (See above.) Posterior Tarsectomy. If the front part of the foot is sound, the posterior part of the tarsus can be removed with or without the tibiotarsal articulation. To remove the astragalus and calcaneum, Oilier first excises the calcaneum and then the astragalus. The anterior inner or outer incision can be added to gain access to the tibiotarsal joint. The malleoli are preserved if possible, and the scaphoid is inserted between them. The posterior or inferior transverse incision of Busch, Hahn, or Bogdanik may be used instead. 886 OPERATIONS OX THE FOOT AND ITS JOISTS. v. Bruns' Tibiocalcaneal Resection. — v. Brims showed that it is often possible and of value to preserve the lower part of the caleaneum. He removes the astragalus and the articular surfaces of the tibia, fibula, and caleaneum, and obtains bony ankylosis between the calcaneal plate and lower end of the tibia and fibula. For this an anterior curved incision is best. v. Bruns occasionally uses a posterior transverse incision passing through the tendo Achillis or lateral incisions. Wladimiroff-Mikulicz Osteoplastic Resection. — Wladimiroff and Mikulicz' osteoplastic resection is performed through a transverse incision in the sole connected at either side with a horizontal incision above the heel by two oblique cuts. (Fig. 595.) The plantar incision begins at the Fig. 595. Wludimiroff-Mikulicz' osteoplastic resection, (v. Bergmann.) inner side in front of the tuberosity of the scaphoid, and ends on the outer side of the foot behind the base of the fifth metatarsal. The horizontal portion divides the tendo. Achillis. The foot is flexed strongly, the tibiotarsal joint opened from behind, and the astragalus and caleaneum removed with the soft parts of the heel. The articular surface of the tibia is sawed off with the malleoli; also the surfaces of the cuboid and scaphoid. The posterior tibial and external and internal plantar arteries are ligated and the sawn surfaces brought together with the foot in the equinus position. The soft parts are sutured together with catgut. Bone sutures are not indispensable. The limb is usually | inch longer than the other after operation. The various modifications of the operation have been published by Lossen and Kummer. The results of the operation are generally good. Of 73 cases col- lected by Kohlhaas in 1891, 56 could stand and walk well. In general the operation is only indicated when the soft parts are markedly dis- eased in addition to the process in the bones. If the soft parts are intact, posterior tarsectomy is preferable. The method has been used to lengthen a shortened limb, as in paralytic talipes equinus and atrophy of the leg. (v. Bruns.) Lengthening of an inch or more is possible by the removal of very little bone. Anterior Tarsectomy. The term anterior tarsectomy is applied to transverse resection of the anterior tarsal bones, and finally of part of the metatarsus. Single RESECTION OF THE JOINTS OF THE TOES. 887 tarsal hones may be removed without greatly impairing the function of the foot, but the operation is rarely indicated, as usually more than one hone or joint is affected. Transverse resection of the tarsus can be performed through two lateral longitudinal incisions. The tissues are lifted off on the dorsum ami in the sole, and the portion of the tarsus and the metatarsus to he removed can he sawed off transversely. The bones are more accessible through a long curved dorsal flap incision. After the resection is com- pleted the wound is packed for a few days or closed primarily. The sawn surfaces are apposed to favor bony union. The latter is better insured by resecting with saw or chisel in sound bone than through the joints. The tendons are sutured, and the wound closed partially and drained at the sides. Witzel's suggestion to employ the incision for Chopart's amputation and preserve the toes can only be considered if Chopart's joint and the toes and plantar tissues are intact. Witzel makes a transverse incision from the tuberosity of the scaphoid over the dorsum to a finger's breadth above the base of the fifth metatarsal, and from either end two longi- tudinal incisions toward the toes, connecting the anterior ends of the latter by another transverse incision over the dorsum, thus removing a quadrilateral portion of the skin with the bones. Transverse resection of the diseased bones and tissues follows. The stumps are approx- imated and are supposed to heal together by fibrous union, giving a certain amount of elasticity to the foot. RESECTION OF THE METATARSAL BONES. Resection of one or more metatarsals in continuity is seldom indi- cated. Disease spreading to the line of Lisfranc's joint necessitates transverse tarsectomy or tarsometatarsal resection. In osteomyelitis or traumatic necrosis of single metatarsals the bone may be removed as the growth of bone from the periosteum and the epiphyses may be adequate, especially in young subjects. Otherwise amputation is preferable, as the cicatricial contraction resulting from the necrosis produces a troublesome deformity. Resection can be performed through a longitudinal incision at the side of the extensor tendon, preserving the epiphysis and joints if possible. In the first metatarsal the epiphysis is proximal, in the others distal. RESECTION OF THE JOINTS OF THE TOES. Resection of the metatarsophalangeal joint applies almost exclusively to the great toe. (See page 854.) Resection of the interphalangeal joints is analogous to the operations on the fingers, and is only indi- cated for contractures. As the loss of a toe is of slight importance, it is unprofitable to preserve a digit that is rendered useless or troublesome bv deviation or contracture. INDEX ABRACHIA, 117 Abscess of axilla. 80 of muscles of upper arm, 144 of popliteal space, 654 treatment of, 654 Accident and judgment, 263 Acromegaly of hand, 351 Acromial bursitis, 7S Adenitis of axilla, 80 tuberculous, 80 cubital, 143 syphilitic, 143 inguinal, 522 suppurative, 522 syphilitic, 522 Ainhum, 774 Aluminum acetate for ulcers of leg, 686 Amelia, 117 Amputation of ankle, 873 Pirogoff's, 873 Syme's, 873 of arm, spontaneous, 117 upper, 158 at elbow-joint, 226 of fingers, 378, 379 phalanges of, 379 of forearm, 259 of hand, 377 of hip-joint, 527 Eranke, 528 haemostasia in, 527 Braun's method of, 527 Biingner's method of, 527 Davy's method of, 527 v. Esmarch's method of, 527 Larrey's method of, 527 McBurney's method of. 527 Riedel's method of, 527 Rose's method of, 527 Schonborn's method of, 527 Trendelenburg's method of. 527 mortality of, 529 Quenu's, 528 Rose's, 527 subperiosteal, 528 of Vetch and Ravaton, 528 of v. Volkmann, 528 transfixion method, 527 Yerneuil's, 527 at knee, 713 of leg, 713 Amputation, Malgaigne's, 876 at mediotarsal joint, Chopart's, 877 of metacarpals, 377 of metatarsals, 879 Pirogoff's osteoplastic, 873 of shoulder, 108 interscapulothoracic, 112 of single metatarsals and toes, 879 subastragaloid, 876 Syme's, 873 Textor's, 877 of thigh, 562 Abrashanow's, 564 Buchanan's, 563 Cardan's, 563 Djelitzyn's, 563 Farabeuf's, 562 Gritti's, 562 Jacobson's, 564 Spence's, 562 Ssabanejeff's, 563 through metatarsals, 879 Sharp's, 879 tarsometatarsal joints, 879 Lisfranc's, 879 of toes, 880 Aneurism of axilla, 81 arteriovenous, 82 symptoms of, 81 treatment of, 82 of brachial artery, 145 cirsoid, of hand, 36S of femoral artery, 549 of foot, 862 diagnosis of, 862 treatment of, 862 of humerus, 151 of leg, 689 symptoms of, 689 treatment of, 6S9 popliteal, 654 symptoms of, 655 treatment of, 655 by extirpation, 656 by ligation, 656 and excision, 656 by Matas' arteriorrhaphv, '657 of thigh, 549 treatment of, 549 Angioma of foot, 870 of muscles of upper arm, 144 Ankle, diseases of, 773 (S89) 890 INDEX. Ankle, inflammations of, acute, 773 treatment of, 773 chronic, 773 -joint, amputation of, 873 anatomy of, 717 inflammations of, acute, 781 treatment of, 782 injuries of, 728 complicated, 766 treatment of, 767 compound, 766 treatment of, 767 physiology of, 717 resection of, 880 by anterior transverse in- cision, 884 sprains of, 728 treatment of, 728 synovitis of, acute, 781 gonorrheal, 782 hemorrhagic, 782 in infectious diseases, 782 serous, 781 suppurative, 782 treatment of, 782 tabetic disease of, 869 Charcot, 869 skin of, tuberculosis of, 774 Ankylosis of hand, 356 of hip-joint, 501 diagnosis of, 504 symptoms of, 503 treatment of, 505 ambulant, 505 forcible reduction, 505 Hoffa's apparatus, 507 Lorenz' apparatus, 506 operative, 508 of knee-joint, 626 prognosis of, 627 treatment of, 627 of shoulder-joint, 98 treatment of, 99 Arm. erysipelas of, 143 malignant oedema of, 143 phlegmonous processes of, 143 upper, amputation of, 158 evulsion of, 141 injuries of, gunshot, 139 diagnosis of, 140 treatment of, 140 malformations of, 117 muscles of, abscess of, 144 angioma of, 144 diseases of, 144 gumma of, 144 hernia of, 119 injuries of, 118 ossification of, 144 rupture of, 119 diagnosis of, 120 etiology of, 119 prognosis of, 120 symptoms of, 120 treatment of, 120 Arm, upper muscles of, wounds of, 118 nerves of, diseases of, 145 injuries of 122 course of, 122 prognosis of, 122 symptoms of, 122 treatment of, 123 neuroma of, 145 diagnosis of, 146 prognosis of, 146 treatment of, 146 operations on, 156 prothesis for, 159 shaft of, resection of, 157 skin of, neoplasms of, 144 tumors of, 144 soft parts of, diseases of, 143 injuries of, 118 syphilitic myositis of, 144 vessels of, diseases of, 145 injuries of, 121 diagnosis of, 121 prognosis of, 121 subcutaneous, 121 treatment of, 121 wounds of, severe lacerated, 141 Arteriorrhaphy, Matas', 657 Arteriovenous aneurisms of axilla, 82 Arteries at elbow-joint, ligation of, 227 of leg, ligation of, 715 Artery, axillary, injuries of, 20 ligation of, 105 brachial, aneurism of, 145 injuries of, 121 ligation of, 156 cubital, ligation of, 227 femoral, aneurism of, 549 injuries of, 532 ligation of, 559 radial, ligation of, 259 at wrist, 375 subclavian, injuries of, 20 ligation of, 22 tibial, anterior, ligation of, 715 posterior, ligation of, 716 ulnar, ligation of, 259 at wrist, 375 Arthritis deformans, 785 coxa vara in, 518 of elbow-joint, 212 of foot, treatment of, 785 of hand, 348 neuropathic, 350 of hip-joint, 494 diagnosis of, 497 etiology of, 497 pathological anatomy of, 495 prognosis of, 499 symptoms of, 497 treatment of, 499 of knee-joint, chronic, 619 Arthropathy of Charcot of knee-joint, 625 Astragalectomy for club-foot, 822 Astragalus, dislocation of, total, 762 diagnosis of, 763 INDEX. X<)1 Astragalus, dislocation of, total, treat- ment of, 7t>l excision of, 885 fractures of, 7 1 1 diagnosis of, 7 15 i real menl of, 746 resection of, 885 Atheroma of thigh, 557 Avicenna's method for forward disloca- tions of shoulder, 68 Axilla, abscess of, 80 adenitis of, 80 tuberculous, SO aneurisms of, 81 arteriovenous, 82 symptoms of, 81 treat menl of, 82 eczema of, 80 hsematoma <>f, 22 inflammatory processes of, 80 treatment of, 81 neoplasms of, 83 tumors of, 83 Axillary, abscesses, 80 adenitis, 80 artery, injuries of, 20 ligation of, 105 dislocations of shoulder, til prognosis of, 65 symptoms of, 64 treatment of, 65 eczema, 80 furuncle, 80 hydroadenitis, 80 nerves of shoulder, injuries of, 23 vein, injuries of, 23 BARDENHEUER'S extension for dis- located clavicle, 39 for fractured clavicle, 32 for supracondyloid fracture of humerus, 175 treatment of Pott's fracture, 740 Baum's method for dislocated clavicle, 37 Baynton's method for ulcers of leg, 687 Beck's coaptation splint, 307 Beelv's apparatus for hollow foot, 850 plaster-of-Paris splint for leg, 678 splint for club-foot, 814 for fractured humerus, 57 Biceps, rupture, of, 119 tendon, dislocation of, 19 ossification of, 242 Billroth's apparatus for loose shoulder, 102 Bone filling, v. Mosetisi's, 702 suture of Hennequin and Wille, 136 methods of, for humerus, 137 Bones, carpal, fracture of, 300 treatment of, 301 of finger, diseases of, 346 of foot, inflammation of, 781 tuberculosis of, 785 diagnosis of, 788 frequency of, 786 Bones of foot, tuberculosis of, symptoms of, 787 i reatmenl of, 790 of forearm, fractures of, 2 16 upper end of, L89 injuries of, 247 malformai ions of, 243 osteomyelil is of, 2.">.j symptoms of, 255 treatment of, 256 tumors of, 257 of hand, acromegaly of, 351 diseases of, 346 inflammation of, acute, 346 chronic, 348 of leg, fracture of shaft of, 671 syphilis of, 705 tuberculosis of, 703 treatment of, 705 tumors of, 710 of tarsus, suppuration of, 783 of thigh, diseases of, 551 injuries of, 535 of toes, acute inflammation of, 783 treatment of, 784 Bowlegs, 645 Braatz' epaulette dressing, 31 Brachial artery, aneurism of, 145 injuries of, 121 diagnosis of, 121 prognosis of, 121 subcutaneous, 121 treatment of, 121 ligation of, 156 neuritis, 145 Bruck's air cushion, 694 v. Bruns' method for forward dislocation of shoulder, 68 tibiocalcaneal resection, 886 Bubo, indolent, of syphilis of inguinal gland, 522 Burns of fingers, 332 of hand, 332 Bursa achillea anterior, 780 posterior, 780 retrocalcanea, 780 glutei medii, 519 minimi, 519 gluteo-tuberosa, 520 iliac, 519 iliaca posteriori, 520 popliteal, hygroma of, 652 semimembranosa, hygroma of, 652 serous inflammation of, 652 subcutanea femoris, 520 subiliac, 519 tendinis obturatoris interni, 519 trochanteric, deep, 519 superficial, 519 vaginalis obturatoris interni, 519 Bursa- of fingers, diseases of, 346 of foot, diseases of, 780 treatment of, 781 of hand, diseases of, 346 of hip, 519 inflammation of, 519 892 INDEX. Bursar of knee, diseases of, 649 of shoulder, diseases of, 78 Bursitis, acromial, 78 iniragenualis, 651 olecranon, 144 prepatellar, acute, 650 treatment of, 650 chronic, 650 symptoms of, 651 treatment of, 651 tuberculous, 651 prretibialis, 651 semimembranosa, 652 semitendinosa, 652 subdeltoid, 78 tuberculous, 79 subiliac, 521 trochanteric, 521 deep, 521 superficial, 521 Butterfly fracture, 139 CALCANEUM, dislocation of, 705 excision of, 884 Ollier's method, 885 Rigaud's method, 884 fractures of, 740 course of, 749 diagnosis of, 7 Is treatment of, 750 resection of, 884 Ollier's method, 8S5 Rigaud's method, 884 Capitulum of humerus, fracture of, 188 diagnosis of, 189 symptoms of, 188 treatment of, 189 Carbolic gangrene of fingers, 341 of hand, 341 Carcinoma of femur, 557 of foot, 872 of hand, 367, 373 of humerus, 154 Carpal bones, fracture of, 300 treatment of. 301 Carpus, resection of, 380 Cavernoma of hand. 367 Cellulitis of fingers, 322 of foot. 773 of hand, 322 of leg, 684 Charcot's knee-joint. 625 Chondrofibroma, cystic, of femur. 555 Chondroma of femur, 550 of foot, 870 Chopart's amputation at mediotarsal joint, 877 joint. / 1 / dislocation in, 765 Cirsoid aneurism of hand, 368 treatment of, 368 Clavicle, congenital defect of, 17 diseases of, 85 dislocation of, 34 acromial end of, 35 Clavicle, dislocation of acromial end of, downward, 37 diagnosis of, 38 prognosis of, 38 symptoms of, 38 treatment of, 38 upward, 35 diagnosis of. 36 etiology of. 35 prognosis of, 36 symptoms of. 35 treatment of, 37 sternal end of, 38 backward, .40 diagnosis of, 41 etiology of, 40 symptoms of. 40 treatment of, 41 forward, 39 diagnosis of, 39 etiology of, 39 prognosis of, 39 symptoms of, 39 treatment of, 39 upward 39 prognosis of, 40 symptoms of, 40 treatment of, 40 total, 41 prognosis of, 41 symptoms of. 41 treatment of, 41 excision of, 110 fractures of, 26 diagnosis of, 27 etiology of. 27 gunshot, 34 prognosis of, 29 symptoms of. ?1 treatment of, 30 neoplasms of, 85 resection of, 110 syphilis of, 85 tuberculosis of, 85 tumors of, 85 ( Ilavus, 774 subungualis, 776 Club-foot, 800 astragalectomy for, 822 diagnosis of, 812 etiology of, 800 pathological anatomy of, 807 svmptoms of, 812 treatment of, 812 -hand, congenital, 278 Colles' fracture. 286 Complete fracture. See Fractures. Congenital club-hand, 278 coxa vara, 518 defects of clavicle, 17 of leg, 669 dislocation of hip, 389 diagnosis of, 401 etiology of, 389 pathology of, 390 prognosis of, 401 INDEX. 893 Congenital dislocation of hip, symptoms of, 399 treatment of, 102 of radius, I 6 I of shoulder, 18 elevation of scapula, 17 hypertrophy of arm, 117 malformations of foot, 722 Contracted foot, 850 Contractions, cicatricial, of fingers, :>!!• Of hand, 319 Contracture at elbow, 231 of tinners, 356 of foot, 795 paralytic, 795 treat incut of, 797 of hand, 356 of hip-joint, 502 diagnosis of, 504 paralytic, 510 symptoms of, 503 treatment of, 505 of knee-joint, 626 prognosis of, 627 treatment of, 627 by Braatz' sector splint, '629 by Hessing's apparatus,029 by Schede's extension, 628 of shoulder-joint, 98 treatment of, 99 of toes, 851 extension, 856 flexion, 856 lateral, 856 Contusions of elbow-joint, 166 diagnosis of, 166 treatment of, 166 of knee, 565 diagnosis of, 566 prognosis of, 566 treatment of, 567 of shoulder-joint, 44 of wrist, 279 diagnosis of, 280 treatment of, 280 Cooper's method for forward dislocation of shoulder, 68 Corns, 774 Coxa vara, 511 adolescentium, 513 diagnosis of, 516 pathological anatomy of, 514 prognosis of, 517 treatment of, 516 in arthritis deformans, 518 congenital, 518 Kocher's, 513 in osteomalacia, 518 rhachitic, 518 traumatic, 519 Coxitis, in acute osteomyelitis, 458 course of, 461 diagnosis of, 462 pathology of, 458 Coxitis, in acute osteomyelitis, prognosis of, 462 symptoms of, 460 treatmenl of, 163 by direct tnfeel ion, l">. 329 treatment of. 329 of hand. 329 treatment of. 329 of leg. 684 G ANGLION of knee. 653 of wrist. 365 treatment of, 366 INDEX. 901 Gangrene of fingers, carbolic, 341 diabetic, 339 treatment of, 341 presenile, 338 senile, 338 of foot, S62 earbolic, 865 diabetic, 864 frostbite, 865 presenile, 863 Raynaud's, 865 senile, 862 treatment of, 866 of hand, 338 carbolic, 341 diabetic, 339 treatment of, 341 presenile, 338 senile, 338 Genu valgum, 634 adolescent ium, 634 rhachitic, 634 treatment of, 640 varum, 645 treatment of, 646 Gibney's dressing for sprained ankle, 729 Glands, inguinal, inflammation of, 522 suppurative, 522 syphilitic, 522 Glossy finger, 317 Goldschmidt's apparatus for talipes equinus, 828 Gonorrhoea of hand, 346 Gonorrheal coxitis, 454 tenosynovitis of fingers, 343, 345 of hand, 343, 345 Gout of elbow-joint, 212 of foot, 785 treatment of, 785 of hand, 348 Groin, tumors of, 557 Guerin's method for ulcers of leg, 687 Gumma of muscles of upper arm, 144 Gunshot fracture. See Fractures, of clavicle, 34 injuries of upper arm, 139 diagnosis of, 140 treatment of, 140 wounds of elbow-joint, 197 of hip-joint, 450 diagnosis of, 451 prognosis of, 451 treatment of, 451 of knee-joint, 569 of thigh, 546 Giinther's incision, 877 Gussenbauer's staple, 137 HABITUAL dislocations of shoulder, 76 treatment of, 77 subluxation of knee, 587 Hemangioma of hand, 367 of thigh, 557 Hemarthrosis of knee, 566 Haematoma of axilla, 22 Haemophilia, knee-joint in, 615 prognosis of, 616 treatment of, 616 Hallux valgus, 851 treatment of, 854 varus, 855 Hamilton's extension splint, 131 Hammer-toe, 856 treatment of, 857 Hand, acute inflammatory processes of, 321 amputation of, 377 anatomy of, 265 ankylosis of, 356 bones of, acromegaly of, 351 diseases of, 346 inflammation of, acute, 346 chronic, 348 tuberculosis of, 351 burns of, 332 bursa 3 of, diseases of, 342 carcinoma of, 367, 373 cavernoma of, 367 cellulitis of, 322 cicatricial contraction of, 319 cirsoid aneurism of, 368 treatment of, 368 congenital hypertrophy of, 270 contractures of, 356 deformities of, 356 development of, 270 enchondroma of, 370 erysipelas of, 330 treatment of, 330 exarticulation of, 377 fibroma of, 369 diagnosis of, 369 treatment of, 369 foreign bodies in, 316 frostbites of, 332 prognosis of, 332 treatment of, 332 furuncle of, 329 treatment of, 329 gangrene in, carbolic, 341 diabetic, 339 treatment of, 341 presenile, 338 senile, 338 gout of, 348 hemangioma of, 367 joints of, arthritis deformans of, 348 diseases of, 346 gonorrhoea of, 346 gout of, 348 inflammation of, acute, 346 chronic, 348 neuropathic arthritis of, 350 rheumatism of, 346 suppuration of, 347 syphilis of, hereditary, 349 treatment of, 350 traumatic effusion of, 347 leprosy in, local effects of, 337 lipoma of, 368 902 ISDEX. Hand, lipoma of, diagnosis of, 3G8 treatment of, 369 lymphangitis of, 331 malformations of, 270 moles of, 367 nsevus pigmentosus of, 367 neoplasms of, 365 neuroma of, 370 neuropathic arthritis of, 350 operations on, 374 osteoma of, 372 phlebitis of, 331 phlegmonous processes of, 321 post-traumatic neuritis of, 318 periostitis of, 320 pseudoerysipelas of, 330 prognosis of, 331 symptoms of, 331 sarcoma of, 372 sebaceous cysts of, 369 skin of, tuberculosis of, 333 treatment of, 336 soft parts of, infections of, acute, 329 chronic, 333 subacute, 329 syphilis of, 331 hereditary, 349 primary effects of. 329 treatment of, 330 syphilitic affections of, 336 syringomyelia in, local effects of, 337 telangiectasis of, 367 tendons of, dislocation of, 280 open division of, 282 operations on, 283 plastic, 375 sheaths of, 265 diseases of, 342 subcutaneous laceration of, 281 suture of, 283 tenosynovitis of, 343 gonorrhoeal, 343, 345 syphilitic, 345 tuberculous, 343 traumatic changes in .pints of, 319 trophic disturbances of, 337 tumors of, 365 warts of, 367 treatment of, 367 wounds of, 314 Heidenhain's traction loop for talipes equinus, 828 Hemimelia, 117 Hennequin's bone-suture, 136 Hernia of muscles of arm, 119 of thigh, 534 treatment of. 535 Heusner's apparatus for fractured clavicle, 31 High shoulder, 17 Hip, anatomy of, 385 bursse of, 519 inflammation of, 519 diseases of, 452 dislocation of, 41 (i backward, 417 Hip, dislocation of, bilateral, 432 prognosis of, 432 symptoms of, 432 treatment of, 432 centrally, 431 diagnosis of, 432 symptoms <>\. 432 treatment of, 432 congenital, 389 diagnosis of, 401 etiologv of, 389 pathology of, 390 prognosis of, 401 symptoms of, 399 treatment of, 402 downward, 429 prognosis of, 430 symptoms of, 430 treatment of, 430 forward, 424 prognosis of, 426 symptoms of, 425 treatment of, 426 iliac, 417 diagnosis of, 421 prognosis of, 421 symptoms of. 420 treatment of, 422 infrapubic, 424 sciatic, 418 suprapubic, 424 upward, 430 prognosis of, 431 symptoms of, 430 treatment of, 431 voluntary, 432 injuries of, 416 -joint, amputation of, 527 Franke's, 528 hsemostasis in, 527 Braun's method of, 527 Bunger's method of, 527 Davy's method of, 527 v. Esmarch's method of, 527 Larrey's method of ,527 Riedel's method of .527 Rose's method of, 527 McBurnev's method of, 527 Schonborn's method of, 527 Trendelenburg's meth- od of , 527 Kocher's resection, 599 mortality of, 529 Quenu's, 528 Rose's, 527 subperiosteal, 528 of Vetch and Ravaton, 528 of v. Yolkmann, 528 transfixion method, 527 Verneuil's, 527 ankvlosis of, 502 INDEX. 903 Hip-joint, ankylosis of, diagnosis of, 504 symptoms of, 503 treatment of, 505 ambulant, 505 forcible reduction, 505 Hoffa's apparatus, f>07 Lorenz' apparatus, 506 operative, 508 arthritis deformans of, 494 diagnosis of, 497 etiology of, 197 pathology of, 195 prognosis of, 499 symptoms of, 497 treatment of, 499 contracture of, 502 diagnosis of, 504 paralytic, 510 symptoms of, 504 treatment of, 505 coxitis from acute osteomyelitis, 458 course of, 461 diagnosis of, 462 pathology of, 458 prognosis of, 462 symptoms of, 460 treatment of, 463 by direct infection, 456 diagnosis of, 456 symptoms of, 456 treatment of, 456 following infectious dis- eases, 453 gonorrhceal, 454 in infancy, 455 rheumatism of, acute artic- ular, 455 syphilitic, 455 traumatic, 453 typhoid, 455 deformities of, paralytic, 510 symptoms of, 511 treatment of, 511 dislocation of, paralytic, 510 hysterical, 501 inflammation at, 452 pathological anatomy of, 425 loose, 510 neuralgia of, 501 neuropathic affections of, 501 resection of, 524 Bardenheuer and Schmidt 's, 526 Huter's, 525 Kocher's, 524 Konig's, 524 Langenbeck's, 524 Liicke's, 525 Roser's, 525 Schede's, 525 Sprengel's, 525 Tiling's, 524 of syringomyelia, 501 of tabes, 501 Hip-joint, tuberculosis of, in:; diagnosis of, 17.", differential, »7'.» pathological anatomy of, 463 prognosis of. is:; symptoms of, 471 treatment of, IS.", local, 486 wounds of, gunshot , 150 diagnosis of, 451 prognosis of, 451 treatment of, 451 malformations of, 389 operation at, 524 physiology of, 385 Hoffa's apparatus for talipes calcaneus, 849 Hofmeister's method for forward disloca- tion of shoulder, 69 dressing for dislocation of clavicle, 37 Hoftmann's prothesis for thigh, 564 Holden's toepost, 854 Hollow foot, 850 Housemaid's knee, 650 Hudson's apparatus for talipes equinus, 828 Humerus, aneurism of, 151 carcinoma of, 154 echinococcus of, 151 enchondroma of, 150 exostosis of, 150 prognosis of, 151 treatment of, 151 fractures of, 49 anatomical neck of, 49 intrascapular, 50 supratubercular, 50 capitulum of, 188 diagnosis of, 189 symptoms of, 188 treatment of, 189 complicated, 132 condyles of, 177 external, 181 cause of, 181 diagnosis of, 182 mechanism of, 181 prognosis of, 182 symptoms of, 181 treatment of, 183 internal, 186 prognosis of, 187 treatment of, 187 diacondyloid, 187 epicondyles of, 183 external, 183 treatment of, 184 internal, 184 in epiphysis, 52 diagnosis of, 53 prognosis of, 53 symptoms of, 53 treatment of, 54 infratubercular, 52 lower end of, 167 904 INDEX. Humerus, fractures of, shaft of, 128 etiology of, 128 prognosis of, 129 symptoms of, 129 treatment of, 129 supracondyloid, 169 diagnosis of, 172 etiology of, 169 mechanism of, 169 prognosis of, 176 symptoms of, 171 treatment of, 172 surgical neck of, 54 prognosis of, 55 symptoms of, 55 treatment of, 56 T- and Y-fractures, 177 diagnosis of, 178 etiology of, 177 mechanism of, 177 symptoms of, 178 treatment of, 178 through the tuberosity, 52 tuberosities of, 59 uniting with deformity, 138 upper end of, 49 intracapsular, 50 supratubercular, 50 osteomyelitis of, 147 pseudarthrosis of, 134 anatomical findings of, 135 diagnosis of, 135 etiology of, 134 prognosis of, 135 treatment of, 135 resection of, 157 sarcoma of, 151 diagnosis of, 153 prognosis of, 153 syphilis of, 149 tuberculosis of, 149 tumors of, 149 Hydroadenitis axillaris, 80 Hydrops, intermittent, of knee-joint, 599 Hygroma of thigh, 557 Hypertrophy, congenital, of foot, 722 of hand, 270 Hysterical hip-joint, 501 shoulder-joint, 102 "NFLAMMATIONS of ankle, acute, 773 treatment of, 773 chronic, 773 joint, 781 treatment of, 782 of bones of foot, acute, 781 chronic, 784 of hand, acute, 346 chronic, 348 of bursse of hip, 519 of elbow-joint, acute serous, 210 treatment of, 210 chronic, 212 of foot, acute, 773 treatment of, 773 Inflammations of foot, chrome, 773 of hip-joint, 452 of inguinal glands, 522 suppurative, 523 syphilitic, 522 of joints of foot, acute, 781 chronic, 784 of hand, acute, 346 chronic, 348 of knee-joint, acute exudative, 594 chronic deforming, 619 symptoms of, 620 treatment of, 620 of metatarsal bones, 783 treatment of, 784 of metatarsals in infectious diseases, 784 of tibiotarsal joint, 781 treatment of, 782 Inflammatory diseases of shoulder-joint, 89. See Omarthritis, processes of axilla, 80 treatment of, 81 of fingers, acute, 321 of hand, acute, 321 of thigh, 551 and ulcers of soft parts of leg, 684 Infraction. See Fractures. Infragenual bursitis, 651 Infusion at elbow, 235 Ingrowing toe-nail, 776 treatment of, 777 Inguinal adenitis, 522 suppurative, 522 syphilitic, 522 glands, inflammation of, 522 suppurative, 522 syphilitic, 522 Lennander's operation for, 560 tumors of, 557 region, tumors of, 557 Intermittent hydrops of knee-joint, 599 Interscapulothoracic amputation of shoulder, 112 Intrauterine fracture of leg, 670 JOINTS, ankle, amputation of, 873 anatomy of, 717 inflammation of, acute, 781 treatment of, 782 injuries of, 728 complicated, 766 treatment of, 767 compound, 766 treatment of, 767 physiology of, 717 resection of, 880 by anterior transverse in- cision, 884 sprains of, 728 treatment of, 728 synovitis of, acute, 781 gonorrhoea!, 782 hemorrhagic, 782 INDEX. 905 Joints, ankle, synovitis of, acute, in in- fectious diseases, 782 serous, 7S1 suppurative, 782 treatment of, 782 Chopart's, 717 elbow-, amputations at, 226 anatomy of, 161 arteries at, ligation of, 227 arthritis deformans of, 212 contusions of, 166 diagnosis of, 166 treatment of, 166 diseases of, 210 dislocations of, 198 backward, 199 diagnosis of, 200 irreducible, 202 prognosis of, 201 treatment of, 201 diverging, 206 forward, 206 lateral, 204 diagnosis of, 204 treatment of, 205 of radius at, 207 symptoms of, 207 treatment of, 209 of ulna at, 207 fractures of, 167 complicated, 196 gunshot, 196 free bodies in, 213 symptoms of, 213 gout of, 212 inflammations of, 210 injuries of, 166 ligation of arteries at, 227 locations of nerves at, 227 loose, 225 mechanism of, 161 operations on, 222 resection of, 222 sprains of, 166 diagnosis of, 167 prognosis of, 167 treatment of, 167 suppuration of, 211 syphilis of, 211 tuberculosis of, 215 prognosis of, 216 symptoms of, 215 treatment of, 217 wounds of, gunshot, 197 of finger, diseases of, 346 traumatic changes in, 319 of foot, inflammations of, acute, 781 chronic, 784 tuberculosis of, 785 diagnosis of, 788 frequency of, 786 symptoms of, 787 treatment of, 790 of hand, arthritis deformans of, 348 diseases of, 346 gonorrhoea of, 346 Joints of hand, gout of, 348 inflammations of, 346, 348 neuropathic arthritis of, 350 rheumat ism of, 15 16 suppuration of, 347 syphilis of, hereditary, 349 traumatic effusion in, 347 hip-, amputation of, 527 Franke's, 528 haemostasia in, 527 Kocher's resection of, 599 mortality of, 529 Quenu's, 528 Rose's, 527 subperiosteal, 528 transfixion method, 527 Verneuil's, 527 ankylosis of, 502 diagnosis of, 504 symptoms of, 503 treatment of, 505 arthritis deformans of, 494 diagnosis of, 497 etiology of, 497 pathology of, 495 contractures of, 502 diagnosis of, 504 paralytic, 510 symptoms of, 504 treatment of, 505 coxitis from acute osteomyelitis,. 458 course of, 461 diagnosis of, 462 pathology of, 458 prognosis of, 462 symptoms of, 460 treatment of, 463 by direct infection, 456 diagnosis of, 456 symptoms of, 456 treatment of, 456 following infectious dis- eases, 453 gonorrhceal, 454 in infancy, 455 rheumatism of, acute artic- ular, 455 syphilitic, 455 traumatic, 453 typhoid, 455 deformities of, paralytic, 510 dislocation of, paralytic, 510 hysterical, 501 inflammation at, 452 loose, 510 neuropathic affections of, 501 resection of, 524 of syringomyelia, 501 of tabes, 501 tuberculosis of, 463 diagnosis of, 475 differential, 479 prognosis of, 483 pathological anatomy of,. 463 906 INDEX. Joints, hip-, tuberculosis of, symptoms of, 471 treatment of, 485 wounds of, gunshot, 450 diagnosis of, 451 prognosis of, 451 treatment of, 451 mediotarsal, amputation in, 877 metacarpophalangeal, tuberculosis of, 356 prognosis of, 350 symptoms of. 356 treatment of, 356 metatarsal, dislocation in, 765 metatarsophalangeal, resection of, 887 shoulder-, ankylosis of, 89 treatment of, 99 contracture of, 89 contusions of, 46 diseases of, 89 hysterical, 102 loose, 100 neuroses of, 102 resection of, 106 sprains of, 44 wounds of, 46 of tarsus, suppuration of, 783 treatment of, 783 tibiotarsal, acute inflammations of, 781 treatment of, 782 resection of, 880 of toes, acute inflammations of, 783 treatment of, 784 resection of, 887 wrist-, tuberculosis of, 351 diagnosis of, 352 symptoms of, 351 treatment of, 352 KNEE, amputation at, 713 bursa? of, diseases of, 649 contusion of, 565 diagnosis of, 566 prognosis of, 566 treatment of, 567 deformities of, paralytic, 633 static, 634 diseases of, 594. See also Knee- joint, dislocations of, 582 backward, 583 symptoms of, 584 treatment of, 584 forward, 583 congenital, 587 treatment of, 587 symptoms of, 583 treatment of, 583 menisci of, 591 symptoms of, 592 treatment of, 592 sideways, 584 complications of, 585 Knee, dislocations of, sideways, diagnosis of. 585 symptoms of, 584 treatment of, 586 habitual subluxation of, 587 hsemarthrosis of, 566 injuries of, 565 -joint, ankylosis of, 626 prognosis of, 627 treatment of, 627 contracture of, 626 prognosis of, 627 treatment of, 627 by Braatz' sector splint, '629 by Hessing's appara- tus. 629 by Schede's extension, '628 deformities of, paralytic, 633 static, 634 free bodies in, 621 diagnosis of, 623 symptoms of, 623 treatment of, 623 haemophilia in, 615 prognosis of, 616 treatment of, 616 inflammations of, acute exuda- tive, 594 chronic deforming, 619 symptoms of, 620 treatment of, 620 intermittent hydrops of, 599 neoplasms of, 648 neuralgia of, 624 neuropathic affections of, 624 neurosis of, 624 rheumatism of, chronic, 618 symptoms of, 618 treatment of, 619 synovitis of, 594 acute purulent, 594 seropurulent, 594 serous, 594 chronic, 599 course of, 597 symptoms of, 595 treatment of, 597 syphilis of, 617 treatment of, 618 of syringomyelia, 625 of tabes, 625 tuberculosis of, 600 cause of, 607 pathological anatomy, 600 symptoms of, 604 treatment of, 609 by arthrectomy, 613 by Bier's congestion, '612 bv continuous exten- sion, 600 by immobilization, 609 by iodoform injection, '611 INDEX. 907 Knee-joint, tuberculosis of, treatment I of, by partial opera- tions, 612 bv portable plaster- ' splint, 609 by n-scct ion. 014 tumors of, 6 I s Valleix's pressure points in, 624 wounds of, 568 gunshot, 569 menisci of, dislocation of, 591 symptoms of, 592 treat menl of, 592 neoplasms of, 646 snapping, 633 prognosis of, 634 treatment of, 635 sprains of, 565 diagnosis of, 566 prognosis of, 566 treatment of, 567 tumors of, 646 Knock-knees, 634 Koeher's amputation of shoulder, lnyxis, 776 Operations on arm, upper, 156 on elbow and forearm, 259 -joint, 222 on fingers, 374 on foot and its joints, 873 on forearm, nerves of, 261 on hand, 374 plastic, of tendons, 375 at hip, 524 on leg, 713 on shoulder, 104 on thigh, 559 on wrist, 374 Os calcis. See Calcaneum. Ossification of biceps tendon, 242 910 INDEX. Ossification of muscles of upper arm, 144 Osteoid tumors of femur, 556 Osteoma of foot, 870 of hand, 372 Osteomyelitis of bones of forearm, 255 symptoms of, 255 treatment of, 256 of femur, acute, 551 symptoms of, 552 treatment of, 554 of hip-joint, acute, 458 course of, 461 diagnosis of, 462 pathology of, 458 prognosis of, 462 symptoms of, 460 treatment of, 463 of humerus, 147 of leg, acute, 697 symptoms of, 697 treatment of, 700 modern, 702 by v. Mosetig's method, . 702 varieties of, 697 of metatarsals, 784 of radius, 255 symptoms of, 255 treatment of, 256 of tibia, acute, 697 symptoms of, 697 treatment of, 700 of toes, 784 of ulna, 255 symptoms of, 255 treatment of, 256 Osteosarcoma of foot, 871 PANARITIUM, articular, 324 course of, 325 treatment of, 326 cutaneous, 322 osseous, 324 parungual, 323 subungual, 323 of tendon sheaths, 323 Papilloma in foot, 871 Paralysis of forearm, tendon transplanta- tion for, 240 pressure, of nerves of arm, 124 primary, of musculospiral nerve, 133 secondary, of musculospiral nerve, 133 Paralytic contracture of hip-joint, 510 deformities of hip-joint, 510 symptoms of, 511 treatment of, 511 of knee-joint, 633 dislocation of hip-joint, 510 loose hip-joint, 510 Paronychia, 776 treatment of, 776 Patella, dislocation of, congenital, 589 treatment of, 590 downward, 591 Patella, dislocation of, lateral, 588 prognosis of, 589 treatment of, 589 vertical, 590 symptoms of, 590 treatment of, 591 fracture of, 573 cause, 575 compound, 579 treatment of, 579 prognosis of, 575 symptoms of, 575 treatment of, 576 ambulant, 576 of Kraske, 576 of zum Busch, 576 by bandaging, 576 Bardenheuer's extension, 576 Malgaigne's clamp, 576 by massage, 576 open suture, 578 of Dieffenbach, 578 of Lister, 578 of Rhea Barton, 578 of Severino, 578 subcutaneous suture, 577 of Barker, 577 of Butcher, 577 of Ceci, 577 of Heusner, 577 of Kocher, 577 of v. Volkmann, 577 Trelat's method, 576 refracture of, 581 treatment of, 581 rider-pain of, 565 Periarthritis humeroscapularis, 78 Periostitis, post-traumatic, of fingers, 320 of hand, 320 Perobrachia, 117 Perrin's incision, 877 Pes. See Talipes. Phalanges of fingers, amputation of, 379 dislocation of, 309 treatment of, 310 fracture of, 308 diagnosis of, 308 treatment of, 308 resection of, 384 sequestrotomy of, 384 of foot, fractures of, 768 prognosis of, 769 treatment of, 769 of toes, dislocations of, 770 Phlebitis of fingers, 331 of hand, 331 Phlegmon of foot, 773 of leg, 684 Phlegmonous processes in arm, 143 in hand, 321 Phocomelia, 117 Pirogoff's amputation at ankle, 873 INDEX. 911 Plastic operation on median nerve, 240 on radial nerve, 240 on ulnar nerve, 239 Polydactylia, 272 Popliteal aneurism, 654 symptoms of, (555 treatment of, 655 by extirpation. 05(5 by ligation, 656 and excision, 656 by Matas' artenorrhaphy, ' (i5 7 bursa, hygroma of, G52 cysts, 052 diagnosis of, 653 prognosis of, 653 treatment of, 653 space, abscess of, 654 treatment of, 654 aneurism in, 654 symptoms of, 655 treatment of, 655 vessels, injuries of, 570 treatment of, 571 Post-traumatic neuritis of fingers, 318 of hand, 318 periostitis of fingers, 320 of hand, 320 Pott's fracture, 733 Prepatellar bursitis, acute, 650 treatment of, 650 chronic, 650 symptoms of, 651 treatment of, 651 tuberculous, 651 Presenile gangrene of fingers, 338 of hand, 338 Pretibial bursitis, 651 Prothesis for upper arm, 159 Pseudarthrosis of humerus, 134 anatomical findings of, 135 diagnosis of, 135 etiology of, 134 prognosis of, 135 treatment of, 135 of leg, 682 Pseudoerysipelas of hand, 330 prognosis of, 331 symptoms of, 330 Purulent omarthritis, 91 prognosis of, 91 symptoms of, 91 treatment of, 91 Q UADRICEPS tendon, rupture of, 581 RADIAL artery, ligation of, 259 at wrist, 375 nerve, injuries of, 236 at elbow, 236 plastic operations on, 91 Radius, defect of, 243 diseases of, 255 Radius, dislocation of, congenital, 164 head of, 207 lower end of, 303 fracture of, Mead of, 194 etiology of, 194 symptoms of, 194 treatment of, 194 lower end of, 286 after-treatment of, 299 anatomical findings of, 289 diagnosis of, 293 mechanism of, 287 prognosis of, 299 symptoms of, 292 treatment of, 295 neck of, 195 diagnosis of, 195 symptoms of, 195 treatment of, 195 shaft of, 253 diagnosis of, 254 etiology of, 254 treatment of, 254 malformations of, 243 osteomyelitis of, 255 symptoms of, 255 treatment of, 256 sarcoma of, 257 subluxation of head of, 195 tumors of, 257 and ulna, shaft of, fracture of, 247 prognosis of, 248 symptoms of, 247 treatment of, 249 Raynaud's gangrene of foot, 865 Refracture of patella, 581 treatment of, 581 Resection of astragalus, 885 of calcaneum, 884 Rigaud's method, 884 Olfier's method, 885 of carpus, 380 of clavicle, 110 of elbow-joint, 222 of hip-joint, 524 Bardenheuer's, 526 Huter's, 525 Konig's, 524 Langenbeck's, 524 Liicke's, 525 Roser's, 525 Schede's, 525 Schmidt's, 526 Sprengel's, 525 Tiling's, 524 of humerus, 157 of joints of toes, 887 of metacarpals, 384 of metatarsals, 887 of phalanges of fingers, 384 of scapula, 111 of shaft of upper arm, 157 of shoulder-joint, 106 tibiocalcaneal, of v. Bruns, 886 of tibiotarsal joint, 880 912 INDEX. Resection of tibiotarsal joint, Kocher'>, 884 Konig's, 882 Langenbeck's, 880 Oilier' s, 883 _ Vogt's, 883 Wladimiroff - Mikulicz' osteoplastic, 886 of wrist-joint, 379 Rhachitic coxa vara, 518 curvatures of leg, 706 treatment of, 708 of thigh, 530 treatment of, 530 Rheumatic coxitis, 455 Rheumatism, articular, of metatarsals, 784 of toes, 784 chronic, of foot, 784 of knee-joint, 618 symptoms of, 618 treatment of, 619 gonorrhreal, of metatarsals, 784 of toes, 784 Rice body hygroma of subdeltoid bursa, 79 Riders' bone, 550 treatment of, 551 pain of patella, 565 Riedel's method for forward dislocation of shoulder, 68 Roloff's method for forward dislocation of shoulder, 69 Roser's splint for Colles' fracture, 297 Rupture of biceps, 119 of deltoid, 19 of ligamentum patellae, 581 of muscles of thigh, 533 treatment of, 534 of upper arm, 119 diagnosis of, 120 etiology of, 119 prognosis of, 120 symptoms of, 120 treatment of, 120 of quadriceps tendon, 581 SAMPSON'S toepost, 854 Saphenous vein, ligation of, 694 Sarcoma of femur, 556 treatment of, 557 of foot, 871 subungual, 871 of hand, 372 of humerus, 151 diagnosis of, 153 prognosis of, 153 of radius, 257 of ulna, 257 Sayre's splint, 31 Scapula, congenital elevation of, 17 diseases of, 86 fractures of, 41 acromion and spine, 44 prognosis of, 4o Scapula, fractures of, acromion and spine, symptoms of, 44 treatment of, 45 angles of, 42 body of, 42 diagnosis of, 42 prognosis of, 42 symptoms of, 42 treatment of, 42 eoracoid process of, 45 etiology of, 45 symptoms of, 45 treatment of, 45 glenoid portion of, 43 gunshot, 45 surgical neck of, 43 prognosis of, 44 symptoms of, 44 treatment of, 44 neoplasms of, 80 resection of, 111 tumors of, 86 Scarpa's splint for club-foot, 815 Schede's splint for Colles' fracture, 298 Schinzinger's method for forward dis- location of shoulder, 66 Schiissler's apparatus for loose-shoulder, 601 Sciatic nerve, open stretching of, 561 Sciatica of thigh, 551 treatment of, 551 Scudder's dressing for fractured clavicle, 30 humerus, 57 Sebaceous cyst of hand, 309 Senile gangrene of fingers, 338 of hand, 338 Sensory disturbances of foot, 869 treatment of, 870 Sequestrotomy of metacarpals, 3S4 of phalanges, 384 Sharp's amputation through metatarsals, 879 Shoe, correct shape of, 842 for flat-foot, 842 of Beelv, 843 of Miller and Thomas, 843 plate of Hoffa, 843 of Whitman, 844 Shoulder, amputation at, 108 intrascapulothoracic, 112 bursa? of, diseases of, 78 congenital elevation of, 17 dislocations of, 60 backward, 71 infraspinate, 71 diagnosis of, 72 prognosis of, 72 symptoms of, 71 subacromial, 72 congenital, 18 deltoid paralysis following, 70 forward, 61 axillary, 61 anatomical findings of, 62 INDEX. 913 Shoulder, dislocations of, forward, axil- lary, diagnosis of, •'. I prognosis of, 65 symptoms of, 64 treat menl of, 65 subcoracoid, 61 habitual, 7<> treatment of, 77 old, 73 anatomy of, 73 prognosis of, 71 symptoms of, 7 1 treatment of, 75 -joint, ankylosis of, 89 treatment of, 99 contracture of, 99 treatment of, 99 contusions of, 44 diseases of, 89 hysterical, 102 loose, 100 neuroses of, 102 resection of, 106 sprains of, 44 tuberculosis of, 92 wounds of, 46 prognosis of, 48 treatment of, 48 muscles of, injuries of, 19 nerves of, injuries of, 23 diagnosis of, 24 prognosis of, 25 symptoms of, 24 treatment of, 25 operations on, 104 skin of, injuries of, 19 soft parts of, neoplasms of, 84 tumors of, 84 vessels of, injuries of, 20 prognosis of, 22 treatment of, 22 Skin at elbow, diseases of, 229 of shoulder, injuries of, 19 of thigh, tumors of, 557 of upper arm, neoplasms of, 144 tumors of, 144 Snapping finger, 363 knee, 633 prognosis of, 634 treatment of, 634 Spina ventosa, of fingers, 353 Spinal fracture. See P'ractures. Splint, v. Brims', for leg and thigh, 541 Buck's extension, 545 extension for femur, 540 Helferich's extension for femur, 541 Hessing's, for thigh, 542 Hodgen's suspension, 545 Schede's suspension for thigh, 542 v. Yolkmann's, 540 Splinter fracture. See Fractures. Sprains of ankle-joint, 728 treatment of, 728 of elbow-joint, 166 diagnosis of 167 prognosis of, 167 Vol. III.— 58 Sprains of elbow-joint, treatment of, 1 <)7 Of knee, 505 diagnosis of, 566 prognosis of, 566 treatmenl of, 567 of shoulder-joint . 1 I of wrist , 27!» diagnosis of, 280 treatment of, 280 Sprengel's deformity, 17 Static deformities of knee, 634 Stimson's fenestrated splint lor leg, 079 method for dislocated clavicle, 39 for forward dislocation of shoul- der, 68 splint for Colles' fracture, 299 for fractures of humerus, 174 for Pot fc's fracture, 7 10 Storp's suspension cuff, 298 Stretching of nerves of thigh, 561 Subastragaloid amputation, 876 dislocation, 758 backward, 760 forward, 760 inward, 758 onward, 7(50 outward, 759 Subclavian artery, injuries of, 20 ligation of, 22 vein, ligation of, 104 Subcoracoid dislocations of shoulder, 61 Subdeltoid bursitis, 78 tuberculous, 79 Subiliac bursitis, 521 Subluxation of head of radius, 195 of knee, habitual, 587 Subungual growths in foot, 870 Supernumerary- digits, 272 toes, 722' Suppuration of bones of tarsus, 783 treatment of, 783 of elbow-joint, 211 of joints of tarsus, 783 treatment of, 783 of tendon sheaths of fingers, 323 Suppurative inflammation of inguinal glands, 522 Supracondyloid fracture of humerus, 169 diagnosis of, 172 etiology of, 169 mechanism of, 169 prognosis of, 176 symptoms of, 171 treatment of, 172 Supramalleolar fractures, 731 diagnosis of, 732 prognosis of, 733 treatment of, 733 Syme's amputation at ankle, 873 Synovial sacs at elbow, diseases of, 233 injuries of, 233 Synovitis of ankle-joint, acute, 781 gonorrhceal, 782 hemorrhagic, 782 in infectious diseases, 782 serous, 781 914 INDEX. Synovitis of ankle-joint, suppurative, 782 treatment of, 782 of knee-joint, 594 acute purulent, 594 seropurulent, 594 serous, 594 chronic, 599 course of, 597 symptoms of, 595 treatment of, 597 Syphilis of bones of leg, 705 of clavicle, 85 of elbow-joint, 211 of fingers, 329 of foot, 774 of hand, 331 hereditary, 349 primary effects of, 329 treatment of, 330 of humerus, 149 of knee-joint, 617 treatment of, 618 of tibia, 705 Syphilitic affections of fingers, 336 of hand, 336 of skeletal foot, 785 coxitis, 455 cubital adenitis, 143 inflammation of inguinal glands, 522 myositis of upper arm, 144 tenosynovitis of fingers, 345 of hand, 345 Syringomyelia in fingers, effects of, 337 in hand, effects of, 337 of knee-joint, 625 Szymanowski's towel dressing, 30 TABETIC diseases of ankle-joint, 869 hip-joint, 501 knee-joint, 625 of tarsus, 869 Talipes calcaneus, 846 sensu strictiori, 846 sensuni plexus, 846 treatment of, 848 cavus, 850 equinus, 824 pathological anatomy of, 826 symptoms of, 826 treatment' of, 827 valgus, 829 varus, 800 Tarsal bones, dislocations of, 758 small, fractures of, 750 treatment of, 751 Tarsectomy, anterior, 886 for club-foot, methods of, 821 posterior, 885 Tarsus, bones of, suppuration of, 783 treatment of, 783 fractures of, 744 joints of, suppuration of, 783 treatment of, 783 tabetic disease of, 869 Tear-fracture of spine of tibia, 582 Telangiectasis of foot, 870 of hand, 367 Tendo Achillis, subcutaneous division of, 821 Tendons of elbow, diseases of, 233 injuries of, 233 of foot, dislocations of, 729 treatment of, 730 injuries of, 729 lacerations of, 730 treatment of, 730 transplantation of, 798 of forearm, diseases of, 233 injuries of, 233 of hand, dislocations of, 280 open division of, 282 operations on, 283, 375 subcutaneous laceration of, 281 suture of, 283 sheath at elbow, diseases of, 233 injuries of, 233 sheaths of fingers, blood extravasa- tion in, 342 diseases of, 342 gonorrhoea of, 343 panaritium of, 323 suppuration of, 323 syphilis of, 343 tenosynovitis of, acute ser- ous, 342 tuberculosis of, 343 of foot, diseases of, 778 treatment of, 780 of hand, 265 blood extravasation, 342 diseases of, 342 gonorrhoea of, 343 syphilis of, 343 tenosynovitis of, acute ser- ous, 342 tuberculosis of, 343 transplantation in foot, 798 for paralysis of forearm, 240 for talipes calcaneus, 849 at wrist, 375 Tenosynovitis of fingers, 343 gonorrhceal, 343, 345 syphilitic, 345 tuberculous, 343 of hand, 343 gonorrhceal, 343, 345 syphilitic, 345 tuberculous, 343 Textor's amputation, 877 T-fractures of condyles of humerus, 177 diagnosis of, 178 etiology of, 177 mechanism of, 177 symptoms of, 178 treatment of, 178 Thigh, amputation of, 562 Abrashanow's, 564 Buchanan's, 563 Cardan's, 563 Djelitzyn's, 563 i\di:x 915 Thigh, amputation of, Farabeuf's, 562 Gritti's, 562 Jacobson's, 564 Spencer's, 562 Ssabanejeff's, -~»« "•;> aneurism of, 5 19 treatment of, 5l'.i bone of, diseases of, 551 injuries of, 535 tumors of, 555 carcinoma of, 557 chondrofibroma of, cystic, 555 chondroma of, 556 curvatures of, 530 rhachitic, 530 treatment of, 530 deformities of, 530 due to epiphyseal maldevelop- ment, 530 lower end of, 530 treatment of, 531 phocomelia, 530 treatment of, 530 rhachitie, 530 treatment of, 530 diseases of, 549 echinoeoceus of, 557 enehondroma of, 555 fibroma of, 556 Hoffmann's prothesis for, 564 inflammatory processes of, 551 lipoma of, 556 lymphangiectasis of, 550 treatment of, 550 lymphatics of, diseases of, 550 muscles of, diseases of, 550 hernia of, 534 treatment of, 535 injuries of, 533 rupture of, 533 treatment of, 534 tumors of, 557 myxoma of, 556 neoplasms of, 555 nerves of, diseases of, 551 stretching of, 561 tumors of, 558 operations of, 559 osteomyelitis of, acute, 551 symptoms of, .552 treatment of, 554 riders' bone of, 550 treatment of, 551 sarcoma of, 556 treatment of, 557 sciatica, 551 treatment of. 551 skin of, tumors of, 557 soft parts of, atheroma of, 557 carcinoma of, 557 dermoid cysts of, 557 diseases of, 549 echinoeoceus of, 557 elephantiasis nervorum of (v. Bruns), 558 enehondroma of, 557 Thigh, Bofl parts of, fibrolipoma of, 557 fibroma of, 557 hemangioma of, 557 bydroma of, 557 leukemic lymphoma of,558 lipoma of, 557 lymph cysts of, 557 lymphangioma of, 557 lymphosarcoma of. 557 myxoma of, 557 neoplasms of, 557 neurofibroma of, 558 osteoma of, 7,7>~ sarcoma of, 557 tuberculous lymphoma of, 557 tumor- of. 557 transplantation of tendons of, 561 tumors of. 555 varicose veins of, 550 treatment of, 550 vessels of, diseases of, 549 injuries of, 532 ligation of, 559 wounds of, gunshot, 546 Thumb, dislocation of, 311 mechanism of, 311 symptoms of, 312 treatment of. 313 Tibia, fractures of, shaft of, 671 diagnosis of, 674 prognosis of, 675 treatment of, 676 tuberosities of, 572 treatment of, 573 osteomyelitis of, acute, 697 symptoms of, 697 treatment of, 700 syphilis of, 705 tuberculosis of, 703 treatment of, 705 Tibial spine, tear-fracture of, 582 Tibiocalcaneal resection of v. Bruns, 886 Tibiotarsal joint, inflammations of, acute, 781 treatment of, 782 resection of, 880 Toe-nails, diseases of, 775 ingrowing, 776 treatment of, 777 Toes, amputation of, 880 bones of, inflammation of, acute, 783 treatment of, 784 contractures of, 851 extension of, 856 flexion of, 856 lateral, 856 deformities of, 851 inflammation of, in infectious dis- eases, 784 injuries of, 768 complicated, 771 joints of, inflammation of, acute, 783 treatment of, 784 osteomyelitis of, 784 916 INDEX. Toes, phalanges of, dislocation of, 770 resection of, 887 rheumatism of, articular, 784 gonorrhoeal, 784 supernumerary, 722 Torsion fracture. See Fractures. Transplantation of tendons at thigh, 561 Trapezius, traumatic lesions of, 19 Traumatic coxitis, 453 Trendelenburg's operation for varicosi- ties, 694 test for varicosities, 691 Trigger finger, 363 Tripier's amputation, 877 Trochanteric bursitis, 521 deep, 521 superficial, 521 Trophic disturbances of fingers, 337 of foot, 869 treatment of, 870 of hand, 337 Tuberculosis of ankle, skin of, 774 of clavicle, 85 of elbow-joint, 215 prognosis of, 216 symptoms of, 215 treatment of, 217 of fibula, 703 treatment of, 705 of fingers, 354 skin of, 333 symptoms of, 355 treatment of, 355 of foot, bones of, 786 diagnosis of, 788 frequency of, 786 symptoms of, 787 treatment of, 790 joints of, 786 diagnosis of, 788 frequency of, 786 symptoms of, 787 treatment of, 790 skin of, 774 of hand, bones of, 351 skin of, 333 of hip-joint, 463 diagnosis of, 475 differential, 479 pathological anatomy of, 463 prognosis of, 483 treatment of, 485 of humerus, shaft of, 149 of knee-joint, 600 course of, 607 pathological anatomy of, 600 primary osteal, 602 synovial, 600 symptoms of, 604 treatment of, 609 by arthrectomy, 613 by Bier's congestion, 612 by continuous extension, '609 by immobilization, 609 by iodoform injection, 611 Tuberculosis of knee-joint, treatment of, by partial operations, 612 by portable plaster-splint, '609 by resection, 614 of metacarpals, 354 symptoms of, 355 treatment of, 355 of metacarpophalangeal joint, 356 prognosis of, 356 symptoms of, 356 treatment of, 356 of shoulder-joint, 92 of subdeltoid bursa, 79 of tibia, 703 and fibula, 703 treatment of, 705 of wrist-joint, 351 diagnosis of, 352 symptoms of, 351 treatment of, 352 Tuberculous adenitis of axilla, 80 omarthritis, 92 pathology of, 92 prognosis of, 94 treatment of, 94 tenosynovitis of fingers, 343 of hand, 343 Tumors of axilla, 83 of bones of forearm, 257 of clavicle, 85 of foot, 870 of groin, 557 of hand, 365 of humerus, 149 of inguinal glands, 557 region, 557 of knee, 646 -joint, 648 of leg, 709 of radius, 257 of scapula, 85 in shoulder, 84 of skin of upper arm, 144 of thigh, bone of, 555 muscles of, 557 nerves of, 558 skin of, 557 soft parts of, 557 of ulna, 257 ULCERS of foot, perforating, 867 treatment of, 868 of leg, 684 prognosis of, 686 treatment of, 686 by aluminum acetate, 686 ambulant, 687 by continuous elevation, '688 by dusting powders, 687 by excision and grafting, 688 by Hirschberg's method, '688 INDEX. 917 Ulcers of leg, treatment of, by Krause's method, 088 by Mariani's method, 688 by Tuna's zinc-gelatin dressing, 687 Ulna, defect of, 243 diseases of, 255 dislocation of, at elbow, 207 Lower end of, 303 Eracture of, coronoid process of, 189 prognosis of, L90 symptoms of, 190 treatment of, 190 olecranon process of, 190 prognosis of, 192 symptoms of, 190 treatment of, 192 shaft of, 251 etiology of, 251 prognosis of, 253 symptoms of, 252 treatment of, 253 malformations of, 243 osteomyelitis of, 255 symptoms of, 255 treatment of, 256 sarcoma of, 257 tumors of, 257 Ulnar artery, ligation of, 259 at wrist, 375 nerve, diseases of 145 injuries of, 122, 238 course of, 122 at elbow, 238 prognosis of, 122 symptoms of, 122 treatment of, 123 neuroma of, 145 diagnosis of, 146 prognosis of, 146 treatment of, 146 plastic operations on, 233 in upper arm, exposure of, 156 Unna's zinc-gelatin for ulcers of leg, 6S7 VARICOSE veins of leg, 690 treatment of, 693 by ligation of saphe- nous, 694 by Trendelenburg's method, 694 of thigh, 550 treatment of, 550 Vein, femoral, injuries of, 532 saphenous, ligation of, 694 subclavian, ligation of, 104 Veins, varicose, of leg, 690 treatment of, 693 by ligation of saphe- nous, 694 by Trendelenburg's method, 694 of thigh, 550 treatment of, 550 Velpeau dressing, 29 Venesection, neuralgia of, 121 Vessels of arm, upper, injuries of, 121 diagnosis of, 121 prognosis ol , 121 subcutaneous, 121 treatment of, 121 <>f elbow, diseases of, 231 injuries of, 23 1 and forearm, diseases of, 234 injuries of, 234 popliteal, injuries of, 520 treat inent of, 577 of shoulder, injuries of, 20 prognosis of, 22 treatment of, 22 of thigh, diseases of, 549 injuries of, 532 Vogt's resection of ankle-joint, 883 v. Volkmann's apparatus for talipes cal- caneus, 849 splint for leg, 677 Vulpius' aluminum splint for arm, 131 for leg, 676 WARTS of foot, 871 of hand, 367 treatment of, 367 Welander's treatment of inguinal adenitis, 523 Whitman's brace for metatarsalgia, 861 shoe brace, 844 Wille's bone suture, 136 Wing-skin, 229 Witzel's anterior tarsectomy, 887 Wladimiroff-Mikulicz' osteoplastic resec- tion, 886 Wounds of arm, upper, severe, lacerated, 141 of elbow-joint, gunshot, 197 of fingers, 314 serious results of, 317 of hands, 314 of hip-joint, gunshot, 450 diagnosis of, 451 prognosis of, 451 treatment of, 451 of knee, 568 -joint, 568 of muscles of upper arm, 11*8 of shoulder-joint, 46 prognosis of, 48 treatment of, 48 of thigh, gunshot, 546 Wrist, contusions of, 279 diagnosis of, 280 treatment of, 280 dislocation of, 301 single bones of, 303 treatment of, 302 ganglion of, 365 treatment of, 366 injuries of, complicated, 304 treatment of, 305 -joint, tuberculosis of, 351 diagnosis of, 352 918 INDEX. Wrist-joint, tuberculosis of, symptoms of, 351 treatment of, 352 ligation of radial artery at, 375 of ulnar artery at, 375 operations on, 374 sprains of, 279 diagnosis of, 280 treatment of, 280 Y -FRACTURE of condyles of hume- rus, 177 diagnosis of, 178 etiology of, 177 symptoms of, 178 treatment of, 178 z INC-GELATIN, Tuna's, 689 COLUMBIA UNIVERSITY LIBRARIES fhsl.stx) RD31 B45C.1v. 3 2002104563 <^3