ABSTRACTS OF ORTHOPEDIC SURGERY 
FOR 1948 
OFFICE OF THE SURGEON GENERAL 
DEPARTMENT OF THE ARMY 
WASHINGTON, D.C. \ 
APRIL 1951 ABSTRACTS OF ORTHOPAEDIC 
SURGERY FOR 19^8 
Prepared by the Orthopaedic Services 
of 
The Medical Department of the United States Army, 
Department of Defense ABSTRACTS OF ORTHOPAEDIC SURGERY FOR 19^8 
•EDITORIAL STAFF- 
EDITOR-IN-CHIEF 
Oral B. Bolibaugh, Col., MC, USA 
ASSOCIATE EDITORS 
Joseph W. Batch, Lt.Col., MC, USA 
Robert W. Boal, Col., MC, USA 
Ernest A. Brav, Col., MC, U&A 
John T. Brennan, Lt. Col., MC, USA 
Robert S. Brua, Col., USAF, (MC) 
Alfred H. Bungardt, Lt. Col., MC, USA 
Knox Dunlap, Col., MC, USA 
Donald W. Lyddon, Lt. Col., MC, USA 
Harold S. McBurney, Lt. Col., MC, USA 
Oscar S. Reeder, Col., USAF, (MC) 
Sterling J. Ritchey, Lt. Col., MC, USA 
Roy C. Rounds, Lt. Col., USAF, (MC) 
Carl M. Inlander, Col., MC, USA 
August W. Spittler, Col., MC, USA 
Lloyd W. Taylor, Lt. Col., MC, USA 
Milton S. Thompson, Col., MC, USA 
LeRoy 0. Travis, Maj., MG, USA 
Victor B. Vare, Lt. Col., MC, USA 
Winston H. Vaughan, Jr., Lt. Col., MC, USA 
ASSISTANT EDITORS 
Resident and Consultant Steffs of the Orthopaedic Services of the 
Hospitals of the United States Army 
ADVISORY EDITOR 
Alfred R. Shands, Jr., M. D. PREFACE 
The volume of Orthopedic literature has constantly increased 
over the years. The need for a condensation of this literature in 
the form of a ready reference is quite obvious, since few of us have 
the time to read all of the material published on this subject. 
At the suggestion of Dr, A. R. Shands, Jr,, Orthopedic surgeons 
of the military service undertook to review the Orthopedic literature 
of 1948. The Chiefs of the Orthopedic Services of all Army hospitals 
and their resident staffs have abstracted all articles pertaining to 
Orthopedics and closely allied subjects in English and foreign 
languages. 
I wish to express my deep gratitude to all of the contributors 
who cooperated wholeheartedly and gave much of their valuable time 
to this work. I owe a debt of gratitude to Dr. Shands who has so 
ably prepared the material in final form for publication. 
ORAL B. BOLIBAUGH 
Colonel, Medical Corps 
United States Army CONTENTS 
SECTION PAGE 
I Congenital Deformities 1 
II Diseases of Growing and Adult Bone 20 
III Tuberculosis of Bones and Joints 33 
IV Infections of Bones and Joints '43 
Y Arthritis and Allied Conditions 57 
VI Poliomyelitis 95 
YII Neuromuscular Disorders Exclusive of Poliomyelitis 12^ 
YIII Fractures 157 
IX Fracture Deformities 196 
X Tumors of Bones and Soft Tissue 205 
XI Conditions of Lower Part of the Back 219 
XII Conditions Involving the Thorax and Dorsal Spine 271 
XIII Conditions Involving the Hip Joint 279 
XIY Conditions Involving the Knee Joint 302 
XV Conditions Involving the Foot and Ahkle 311 
XVI Conditions Involving the Shoulder and Neck 32^ 
XVII Conditions Involving the Hand and Elbow 3^6 
XVIII Amputations and Prostheses 3 
XIX New Devices, Apparatus and Procedures 371 
XX Research 3^7 
XXI Miscellaneous Subjects UlO 
Subj ect Index 
Author Index U30 
iii F0HSW03D 
When it became evident, during the summer of 19^9» 
that the Archives of Surgery would no longer publish the Pro- 
gress of Orthopaedic Surgery in its present form, and that the 
American Academy of Orthopaedic Surgeons had decided to dis- 
continue its preparation, the undersigned approached Colonel 
Floyd L. Wergeland, Chief of the Education and Training Divi- 
sion of the Office of the Surgeon General of the Army, concerning 
the Army Orthopaedic Services continuing the publication. 
Colonel Wergeland then held a conference with Colonel Joseph 
H. McNinch, Director of the Army Medical Library. It was 
decided that the preparation of this publication could be 
undertaken by the Orthopaedic Services of the Army Hospitals 
and would be made a part of the Army* s training program. 
Colonel McNinch offered the full assistance of the facilities 
and staff of The Army Medical Library for this purpose and 
suggested that the nCurrent List of Medical Literature*1 
Bulletins of the Library published each month be used as a 
source for titles. 
Colonel Oral B. Bolibaugh was appointed by the Office 
of the Surgeon General to be Editor-in-Chief, and the titles 
for the abstracts from the 19*+? literature taken from the 
List of Medical Literature*1 were sent to a selected 
group of orthopaedic surgeons in the Army Hospitals. The 
abstracts were prepared by these orthopaedic surgeons, and 
the residents in the training programs with the assistance 
of some of the consultants, and were returned to Colonel Boli- 
baugh. In July, 1950. Colonel Bolibaugh became Chief of the 
Consultant Services to the Par Eastern Theatre and was unable 
to complete the preparation of the publication. In November, 
1950* the abstracts were sent to the undersigned at the Alfred 
I. duPont Institute, Wilmington, Delaware, and in February, 
1951» the Office of the Surgeon General decided to proceed 
with their publication. 
After reviewing the material and deleting a few abstracts, 
it was thought advisable that, if possible, the remainder should 
be published in full and that the name of the publication 
should be changed to Orthopaedic Abstracts of 19^8, since 
most of the abstracts did not represent progress or new in- 
formation, These have been edited and nut in final form for 
publication b.v the undersigned, and Colonel Knox Dunlap, 
Major Lucius C. Hollister, and Lieutenant Commander A. B, 
Dickson of the resident staff of the Institute. 
iv These abstracts of 1150 or more articles by over 
authors represent a very complete review of the 
orthopaedic literature. The majority of the abstracts are 
excellent prepared; however, some are too long and some too 
short—but it is believed all have importance in teaching and 
research and will be of great value to orthopaedic surgeons 
and other physicians and madical workers desiring information 
from the orthopaedic literature of The undersigned is 
deeply grateful to the Army for the performance of this 
abstracts service and feels he is expressing the opinion of 
all physicians who may read the abstracts, when he says, BIt 
is a Job well done.” The Army is publishing these for dis- 
tribution to the Armed Forces Hospitals and medical installa- 
tions, to medical school and hospital libraries and to inter- 
ested orthopaedic surgeons and other physicians. 
The undersigned wishes to express his particular 
thanks and appreciation to Colonel Oral B, Bolibaugh, the 
group of Army orthopaedic surgeons and all of the others 
who have labored long hours in the preparation of this mater- 
ial. He further wishes to thank Major General Raymond W. 
Bliss, the Surgeon General of the Army, Major General George 
B. Armstrong, the Deputy Surgeon General, and Colonel Floyd 
L, Wergeland, who have made this publication possible. 
April 1951 
A. R, Shands, Jr., M. D, 
Advisory Editor 
V SECTION I 
CONGENITAL DEFORMITIES 
Part A. Prepared by Carl M, Rylander, Col,, M.C., USA 
Congenital Dislocation of the Hip 
Steindler (1) discusses the development of present-day knowledge of 
congenital dislocation of the hip. He very briefly mentions various men 
and methods in the treatment of this condition. Congenital dislocation 
of the hip was first described by Hippocrates and then there was a period 
of silence for 2300 years. Dupuytren in 1826 was the first to give a 
good comprehensive picture of the condition in the modern sense, Sandi- 
fort, Hutton, Bouvier, Guerin, Parise, Lorenz, Putti, Paci and others con- 
tributed to our present-day knowledge. Putti gave us a technique of early 
reduction by the abduction method. In later years he considers that there 
are three definite additions to the treatment; (1) that early abduction 
treatment is the least traumatizing and therefore the most promising, (2) 
accurate concentric reduction of the head aids in the proper development 
of the acetabulum and (3) that prolonged after treatment for the develop- 
ment of the abductors and extensors is essential before weight-bearing is 
permitted. Open reduction has its value but it has limitations. Dost, 
Hagey, Schottstaedt, and Larsen (2) report on the results of treatment of 
congenital dislocation of the hip in infancy, based on 112 dislocations in 
86 patients. They were observed over a period of from 1 to 13 years and 
were treated by several doctors so the methods were varied. As a rule they 
were reduced by the closed method of Denuce. Recently they have used trac- 
tion first, where indicated, and this was done by the Coonse modification of 
the Putti method. Originally the fixation was obtained by plaster for about 
nine months. Recently they have used the abduction bar of Ponseti after 
about five months in casts, if the original treatment was in the first year 
of life. The classification of Severin was the one used in determining 
their results. The normal acetabular index of the newborn was 27*5 degrees 
and between 1 and 2 years of age it was 20 degrees, as determined by 
Kleinberg and Lieberman, In a few normal cases which the authors measured, 
it was from 12 to 28 degrees. The abnormal hips varied from 27.5 to 55 
degrees, most of them being between 30 and Uo degrees. Fifty-one per cent 
of their cases had the acetabular index drop to 27*5 degrees in 3 years, 
decreasing more rapidly during the first year. Development of the acetabulum 
was greatest in those cases which had the least trauma in their treatment. 
Increase in the value of the Y coordinate might be due to a thickening of 
the floor of the acetabulum, soft tissue in the acetabulum or by maladapta- 
tion between the head and the acetabulum. Most of the cases with the Y co- 
ordinate of less than 7 cm, had good results and those with a value of more 
than 7 cm, had poorer results. A delay in the ossification of the head of 
the femur was always present. Aseptic necrosis was noted in 52% of the cases 
being greater with the increase in the age at the time of treatment. Twelve 
per cent showed aseptic necrosis with treatment by abduction alone, Sh% 
with traction and manipulation and 7h% with manipulation alone. Good results 
decreased with the increase in age of the patient at the time of the first 
treatment. 
1 Gill (3) reports a study of 105 cases of dislocations of the hip. 
The original treatment was that of "Bloodless reduction” and 52 of the 
cases were operated upon subsequently. Out of 289 cases which he had 
during this period of time, 27$ were in females; Ul$ of the unilateral 
cases were on the right side; 26.9$ were bilateral. The end results of 
the 53 cases treated without operation in the 105 cases were: perfect 
16$, excellent 10.5$, satisfactory lU$ and failures 10$. The total num- 
ber of failures for both methods was 59$• Perfect, meant perfect func- 
tion and anatomy; excellent indicated perfect function but slight deform- 
ity in the anatomy; satisfactory indicated perfect function but rather 
marked changes anatomically. Failure indicated a recurrence of the luxa- 
tion or subluxation. Many of these cases were improving and he felt that 
eventually some of them could be placed in the next higher classification. 
Some of the operations were done a long period of time after the original 
reduction, some as long as 20 years. Getting a child before 3 years of age 
is important but it is more important to reduce the hip soon after the dis- 
location. A child who does not develop the dislocation before the age of 
walking will do better than one who had the dislocation at birth but did 
not have the reduction until the age of walking. Ninety-four per cent of 
predislocations treated by abduction gave satisfactory results but there 
are other factors which are present which affect the results. Genetic or 
mechanical factors may alter the results as may also constitutional or 
physiological conditions of the mother. Dysplasia or aplasia of the aceta- 
bular roof, if not associated with other structural defects of the hip 
offers the best prognosis for a normal hip with treatment. Aplasia of the 
femoral head is more resistant to treatment and gives poorer results. This 
latter condition is what some people call a Perthes disease but Gill feels 
that this is not a true Perthes, Other severe deformities which prevent 
complete bloodless reduction are; inequality of the head and acetabulum, 
deformities of the head, capsular constriction, shortness of the neck and 
high insertion of the capsule on the femur. Most or all dislocations have 
some degree of anteversion but most of these can be reduced and held in 
internal rotation. If they do not hold, then there are probably some other 
defects which need correction. He thinks that this tends to correct itself 
but some require osteotomy. 
In his conclusions Gill states that 25$ of cases of dislocated hips 
become perfect or excellent and this is increased to 35$ if treated before 
the age of 3 years. Fifteen per cent become satisfactory and 20$ if treated 
before the age of 3 years. Failures come in about 60$ of the cases but 
hS% if treated before the age of three years. The form and degree of dys- 
plasia and the ability of the child to resume normal growth are the main 
factors determining the end results. 
Crego and Schwartzman (U) report a follow-up study of 93 cases of con- 
genital dislocations which have been observed since 1937# Sixty-one of 
these were posterior dislocations, 1? were upward luxations or subluxations 
and 15 reported elsewhere were anterior dislocations. They were followed 
for from 1-15 years, 50$ being observed for 6 years or more. These cases 
were treated by traction first to bring them down into proper position and 
then held in that position for four weeks. The head could then be easily 
replaced into the acetabulum by internal rotation and abduction. They were then held in plaster for about three months, A few of the cases 
could be reduced by gentle manipulation only, without traction but very 
little force was used. Most of the cases required traction by skeletal 
method. All cases could be brought down by traction but only 55$ could 
be seated stably as the only initial treatment. In only lh% could stable 
reduction be maintained. Eighty-five per cent required correction of 
other abnormalities for stable reduction to be maintained. For the cor- 
rection of the dislocation they had to consider (1) the dislocation itself, 
(2) anomalies of the head and neck of the femur, (3) anomalies of the cap- 
sule, and (U) anomalies of the acetabulum. Absence or partial absence of 
the head and neck, they felt, was not amenable to this type of treatment 
and in these they did some type of pelvic support osteotomy. Femoral tor- 
sion was present in 71 cases. This was determined by getting AP x-rays with 
the knees in the neutral position and one in internal rotation. Sixty- 
seven supracondylar osteotomies were done and five of these were redone. 
They were done after the three months of plaster immobilization; threaded 
wires were inserted into the upper fragment which was held in internal rota- 
tion, while the lower portion was rotated externally. They were then kept 
in casts for two more months. Capsular anomalies may be found where the 
capsule has an hour-glass constriction. Some of these can still be reduced 
but the head is not well in the acetabulum but at the end of three months of 
plaster it is well in place. Some however are too far out and an open opera- 
tion is done and this deformity is found. The acetabulum is filled with 
fatty tissue and pannus, and this is removed. Acetabular inadequacy is 
found in almost all the cases but about 50$ develop with treatment. The 
others required operation and if the head did not remain in place after the 
capsule had been opened and the acetabulum cleaned out, then an acetabulo- 
p}.asty was done, that is levering the superior acetabular rim down and holding 
it in place with bone above it. There were forty of these reconstructions 
done. These hips were graded as normal, near normal, satisfactory and fail- 
ures. Ninety-two per cent fall in the first three groups and 8$ were failures. 
No evidence of Perthes disease was seen with this treatment but did occur 
with the more forceful reductions done previously. 
Frankel (5) reports on the results of treatment of irreducible congeni- 
tal dislocation of the hip by arthrodesis. He studied lU cases of arthro- 
desis of the hip but was able to follow only 8 of these. They were 8-15 
years old. Four cases had initial extra-articular fusions in which tibial 
or trochanteric grafts were driven through the head distally into the ilium. 
One required a secondary extra-articular fusion. In two cases no graft was 
used and one of them did not fuse. The average fusion time was two years, 
some in 11 months, and one up to 38 months. Prior to surgery the shortening 
was 3-1/5 inches and after surgery it was 3/Uth inches. He used traction 
prior to surgery for three to eight weeks. He feels that the operation 
should be limited to those of the lower economic level, those who will be 
most likely to do some type of standing work. This gives the best hip as 
far as fatigue and pain is concerned. 
McCarroll (6) has found anterior dislocation in 22,5$ of all congenital 
dislocations. He originally used traction, closed reduction and then open 
reduction and a superimposed massive anterior shelf. Longer observation of 
these cases showed that 5 were fair and six were poor with one good. Since 
then he has been able to do a closed reduction with success in 5 cases (20$) 
and has had good results with these. Five cases had aiacetabular reconstruc- ticn and after 3*6 years one was good, 3 fair and one poor. One case had 
the acetabulum deepened with fair results. He feels that the basis under- 
lying anomaly in the primary anterior dislocation is a defect in the anterior 
acetabular rim. He has tried a large anterior buttress of iliac bone in the 
anterior rim of the acetabulum, first outside the capsule and later inside 
the capsule. Final results of these are not yet available. 
Leveuf (7) distinguishes between luxation and subluxation. In luxation 
there is always interposition of soft tissue between the head and the aceta- 
bulum. There is an hour glass constriction of the capsule; a cartilaginous 
roof pushed down into the joint by the head. The head of the femur is small. 
The ligamentum teres is huge. The acetabulum is fair sized when the soft 
tissue is removed. In subluxation there is no soft tissue interposed. The 
limbus is pushed against the acetabulum. The acetabulum assumes an oval 
shape. The head is large and out of shape. These findings are shown by 
arthrography. In true luxation closed reduction is not possible. In his 
open reductions he finds that their readings of the arthrograms were correct. 
Those cases that failed in closed reduction, showed that there was soft tis- 
sue interposed at operation. The results in 116 cases of primary open reduc- 
tion were given. Eighty-five per cent were well replaced. The head was 
changed by epiphysitis postoperatively in some of the cases, 23$, and of 
these 12% were severe with permanent change in the head. The ligamentum 
teres was present in about half the cases. When it was cut, there was epi- 
physitis in k7% but when there was no ligamentum teres there was epiphysitis 
in only 16%, The ligamentum teres did not bleed when cut except in young 
infants, under two years. There were 81.9$ with perfect or good results, 
that is flexion to 90°and abduction to U5$# The best results were obtained 
in children under 3 years of age but since most of the epiphysitis cases oc- 
curred early, he did not operate normally under two years. The results after 
open reduction with shortening of the femur; of 95 dislocations, 81 were in 
children between 3 and 15 years and the others older than this. Fourteen 
showed perfect results, 16 good, h3 poor and 8 bad. He advocated operation 
in adults only in unilateral cases, in order to give the head a stable place 
to rest but little movement was obtained. Operation after reluxation did 
not give good results but he felt that they were sufficiently good to war- 
rant operation. 
Denis Browne (8) assumes that the hip is dislocated in intra-uterine 
life by a thrust on the knee, in flexion, pushing it out posteriorly and be- 
cause of this, he believes that reduction should be done in the opposite man- 
ner. Active movements of the hip in the acetabulum should have good effects. 
The head can leave the acetabulum only backwards. Because of the ilio- 
femoral band, it can go backwards only with the knee flexed, therefore move- 
ments are permissible as long as the knee is kept back. 
In attempting reduction, the child is placed on his face and the 
affected hip brought into the fetal position. The heel of the surgeon1s 
hand is applied to the greater trochanter, posteriorly, and he pushes for- 
ward, With the other hand he moves the knee up and down through a very 
small angle. He gets a crunching feeling when the head slips back into the 
acetabulum, A cast is then applied in this position and left for one month. 
The knee is included in the cast on the affected side. At the end of this 
time he applies a ring of metal over each thigh and these two rings are con- nected by a metal bar which is held in place by a soft belt. The position 
as shown in a diagram is that of the usual frog position, with the thighs 
in full abduction and external rotation. They are then allowed to be 
around as they choose, on their hands and feet; or on their feet with the 
knees flexed and their buttocks near the floor or semi flexed position with 
knees widely separated. They are removed from this on x-ray evidence, but 
most of them are held for a period of 9 months. If the hip slips out during 
the treatment, the whole procedure is started again. The author states 
that he has treated U2 cases in this manner and all had stable painless 
hips. In three cases he did an open reduction, cut the ilio-femoral band 
and then continued the treatment as above, with good results. 
Other Deformities. 
Wilson (9) discusses congenital anomalies requiring early recognition 
and immediate treatment. He lists a number of conditions other than ortho- 
pedic, which should be recognized early and should be operated or treated 
early for best results. If the first child of parents has defects, the 
second is more likely to have some, than is the child of other parents. 
Those with one deformity are also likely to have other deformities. Spina 
bifida occurs fairly frequently. A few cases are anteriorly and little can 
be done for them. They frequently have hair and pigmentation of the skin 
over the lower lumbar and sacral area. With a meningocele, the meninges 
alone are involved and in the cystic cases 80-90$ die in one year without 
operation. Myelocele has no sac and operation is not of much help. With 
complete paralysis, do not operate. 
Wolman (10) reports on 37 cases of Erb's palsy. This type of palsy 
is confined to muscles supplied by the 5th and 6th cervical nerves. In 
severe cases it involves the deltoid, supra- and infia-spinatus, teres minor, 
biceps, brachialis, brachio-radialis and supinator muscles. It gives a char- 
acteristic deformity, the arm hanging limp at the side, elbow extended, and 
hand and arm rotated medially so that the hand faces posteriorly. There are 
no sensory changes. It is due to the stretching of the supra-clavicular 
portion of the brachial plexus during birth, A few more cases have been 
reported in males than females and a few more on the left than on the right 
side. Fifty-four of 125 cases were in primigravida. Thirty-four cases 
were breech deliveries. Forty-seven cases were forceps deliveries in the 
vertex presentation and 11 in the breech presentation. All but 5 of the 
cases weighed 8j pounds or more. Treatment consists in placing the arm 
in a light metal splint with the arm in abduction and external rotation, 
the elbow flexed to 90° and the forearm supinated. Exercises are given by 
hanging colored balls over the crib. The author also gives massage and pass- 
ive exercises. Treatment should begin early, preferably before the end of 
the first month. Those cases which he was able to follow, showed excellent 
results if started early. If delayed, the final results were much poorer. 
Surgery is not recommended. 
Gray (11) described the dissected specimen of an amputated leg in a 
three year old boy with congenital absence of the tibia, as well as an ab- 
sence of the talus, navicular, three cuneiforms, two medial metatarsals and 
three medial toes. He also had absence of some of the muscles of the leg. 
The deficiency of the tibia may be complete or partial and if the latter, 
the lower end is absent. There may be just a fibrous cord representing the 
5 tibia* Other congenital abnormalities are frequently present. In these 
cases, the mother’s health is usually reported as good during her pregnancy. 
There is usually no family history of congenital abnormalities. Two cases 
were reported, however, in which the father and son both had absence of the 
tibia. The cause of this condition is not known. The author suggests that 
the defect is due to failure of differentiation of the blastema of the tib- 
ial anlage. He thinks thatlhis condition can be induced in the embryo if it 
is exposed to harmful environment at the appropriate stage of development. 
Jebens (12) discusses congenital dislocation of the shoulder as seen 
in a 16 year old girl. Some abnormality of the right shoulder was noticed 
a few days after birth and she was treated in the hospital for a few weeks 
in an abduction splint. Her father and three brothers had severe deformi- 
ties of their hands and feet. She had considerable limitation of motion of 
her arm. X-rays showed a deformed humeral head in backward dislocation. 
The glenoid was rudimentary. The acromion arched downward and the coracoid 
process was greatly elongated. Only 21 cases had been reported at the time. 
According to Baker (13) metatarsus varus is quite common in children 
but it is often minor and usually corrects itself. It is most noticeable 
when they begin to walk. With it they usually have an overactive abductor 
hallucis. This condition is frequently missed by the pediatrician until 
the infant begins to walk. The author discusses the structure of the foot 
and its evolution from the primitive mammalian foot. He also discusses the 
weight which is placed on various parts of the foot on walking. The first 
metatarsal is of special importance as it supports the medial side of the 
foot, and prevents depression of the sustentaculum tali; it supports the 
major share of the static stress in locomotion, and it gives support to the 
talus. Certain deviations from the normal which are inherited and represent 
a failure of full development can result in foot strain; 1, Short first 
metatarsal; 2. Posteriorly placed sesamoids under the first metatarsal; 
Hypermobility of the first metatarsal; U. Metatarsus varus; 5. Short heel 
cord. Metatarsus varus does exist in adults as seen by x-rays but is often 
difficult to diagnose without the x-rays. The author prefers to treat the 
metatarsus varus by applying casts in some correction, and at the end of one 
week, wedge the cast at the tarso-metatarsal area. At the end of the second 
week, a new cast is applied and the procedure is repeated. This is continued 
until correction is obtained. This may require months of treatment. At the 
end of this time, corrective shoes should probably be worn. Milder cases, 
can, at times, be corrected by stretching, several times per day. 
Lucas, (1U), reports on surgical procedures in the treatment of chronic 
clubfoot, based on the treatment of 321 cases. Cases treated by conserva- 
tive treatment only, were not included. He advised the Kite cast method of 
treatment as the best for general use. One must have a thorough knowledge 
of all the factors involved before starting the treatment of a case. In- 
form the parents of the possibility of recurrence. Make frequent checks of 
the patient for several years, even after operative correction. They should 
have a balance of their muscles. Soft tissue surgery may be all that is 
necessary but it should be followed by supervised physical therapy. Achil- 
les tendon lengthening may be necessary if unable to get the correction by 
manipulation and casts, but should be done only after the forefoot and tar- 
sal varus has been corrected. Posterior capsulotony may be necessary. A 
persistent deformity that may persist is a cavus foot. If this does not correct with gentle manipulation, then you may do a plantar fasciotony, He 
prefers a lateral approach forlhis operation as there is less danger of dam- 
age to the vessels and nerves. If there is contraction of the scar, after 
the wound has healed, this scar will then tend to preserve the correction. 
Exercises and stretchings are continued following surgery. With weak per- 
oneals and a strong anterior tibial muscle, he transplants the anterior 
tibial tendon to the anterior or antero-lateral portion of the dorsum of 
the foot. The tendon should be well anchored in bone. He usee an operation 
devised by Dillehunt, An incision is made from the heel forward, under the 
medial malleolus up to the first metatarsal joint. The posterior capsule 
and deltoid ligament are cut and the Achilles tendon is lengthened. At 
times, he lengthens the posterior tibial tendon, cuts the subastragalarj 
astragaloscaphoid and scaphocuneiforra capsules and ligaments. Care should 
be taken not to injure the cartilage of the joints. Casts are then applied 
in as much correction as the patient will tolerate. Change the cast in 
three weeks and get the full correction at that time. Circulation may be 
so embarrassed with this that it is necessary to check it carefully. If 
one is unable to get correction of the varus of the calcaneus, then do an 
osteotomy on the lateral side, using a notch in it to prevent it from slip- 
ping back. In obstinate cases, do a triple arthrodesis. In this operation, 
the bones should be made to fit together accurately. The author feels that 
tibial torsion is a factor in maintenance of the deformity but this usually 
disappears after the foot is corrected. If it persists he does an osteotony 
at the upper end of the tibia, making it notched, so that it will not slip. 
The fibula is not cut. He advocates the mildest form of treatment which 
will give correction. 
Goldenberg (15) states that in the available literature, there is no 
report of congenital bilateral complete absence of the radius in twins, 
He shows radiographs of two boys who were born in 1938 with this condition. 
They were operated upon in 19U7, at which time the end of the ulna was 
split and the radial half inserted into a notch between the 2nd and 3rd 
metacarpals. The left side was successful but the right failed, having 
an absorption of the graft in both patients. The left side gave consider- 
able improvement in the condition of the hand. 
Rampoldi (16) analyzes the findings through three generations of con- 
genital hip dislocation occurring in one family. The male in the first 
generation showed a deformity of the sacrum by radiological examination. 
The second generation consisted of 11 individuals, all but two of whom 
showed some congenital deformity. Two females presented shallow acetabula, 
one male showed a deformity of the sacrum, four females had congenital dis- 
locations of the hip and in two patients there was coxa valga. The third 
generation consists of twelve individuals non© of whom shows any deformity 
except for one male who presented a coxa valga. The author concludes that 
the deformities show recessive rather than dominant characteristics. Part 3* Prepared by Sterling T. Ritchey, Lt. Col., M. G., U. S, A. 
Realizing that the greatest number of congenital deformities appear 
in the first eight weeks of prenatal life which is the period of the 
greatest fetal growth rate, MacLean (17) classifies the cause of congeni- 
tal deformities as those due to; T. genetic factors (mutations due to 
radiation, chemicals, and somatic causes) and 2. environmental factors 
(such as nutritional, chemical, endocrine, actinic, infectious, and mech- 
anical). The controversial somatic genetic theory postulates that during 
embryonic development a mutation occurs in one cell which thereafter is 
transmitted only to the descendants of that cell. In early stages of di- 
vision then, this would involve large segments of the final fetus. For in- 
stance if it occurred in the first division stage it would result in changes 
in half of the fully developed body. The author lists deformities inherited 
by the dominant mode such as brachydactylisra, polydactylisra, syndactylism, 
cleidocranial dyostosis, multiple exostoses, achondroplasia, and those in- 
herited by the recessive mode,i.e. polydactylisra, spina bifida, congenital 
dislocation of the hip. 
The environmental factors that adversely affect the embryo in early 
life are many. Nutrition of the ova as affected by its own 
connection to the maternal host has been repeatedly proven to be related 
to congenital deformities. Measles in the first trimester may alter the 
environment of the eye by resultant vascular changes resulting in catar- 
act. Local effects on the embryo by starvation of the maternal host are 
more than probable and certain dietary deficiencies have been proven to 
cause developmental defects of the fetus. This has been repeatedly pro- 
ven by animal experiments. Lack of copper in the diet of the sheep uni- 
formly results in paralysis of the hind extremities of the offspring. 
Iodine deficient diets in sows uniformly result in deformities of the 
offspring such as brittle hooves and patent foramen ovale and these de- 
formities are prevented by the feeding of iodine. The well known endemic 
effects of lack of iodine in the human diet and the resultant cretinism 
is cited. In swine the lack of vitamin A results in sterility, fetal 
death, weak offspring, blindness and other miscellaneous defects. These 
changes are reversed in subsequent litters by the feeding of Vitamin A. 
Rats fed upon a riboflavin deficient diet gave birth to litters, one- 
third of which had congenital skeletal defects and again this pattern 
was reversed by the feeding of riboflavin in subsequent pregnancies. 
Lack of Vitamin D in the human has been well known to cause congenital 
rickets. 
The effects of chemicals upon the embryo have been proven experi- 
mentally with fish, and the pattern of the defect created is dependent 
upon the time at which the injury was inflicted rather than the type of 
chemical used. It is quite probable that there is an effect of endocrine 
influence upon the developing embryo. The pregnant rat given androgen 
results in a depression of the female sexual characteristics of the off- 
spring and the administration of estrogen inhibits the male sexual char- 
acteristics and results in overdevelopment of the female sexual organs. 
8 Insulin probably has some effect upon the embryo, as diabetic mothers can 
expect to have a higher fetal mortality rate and this is definitely re- 
duced by the use of insulin. The effect of irradiation of the developing 
embryo has been proven beyond doubt, but margins of safety and the remote 
and subsequent generation defects have not been firmly established. The 
infectious factors influencing the embryo are well established by the known 
effects of measles during the first trimester of pregnancy. There is 
strong likelihood of the child of a mother who has suffered measles during 
the first two months of her pregnancy to be born with congenital catar- 
acts, congenital heart disease and other miscellaneous defects. In one 
series of eleven cases of mongolism nine were associated with a maternal 
infection during the second or third month of pregnancy and it is commonly 
believed that mongolism is not the result of maternal endocrine factors. 
Certain mechanical factors still are related to congenital defects. 
This cause is related to scanty amniotic fluid and amniotic bands and is 
characterized by pressure narks on the infant and points of pressure 
atrophy over bony protuberances. 
Stevens (18) reports identical twins, age twelve, both with congeni- 
tal torticollis as the first such case report known. The birth history 
was not obtainable, the mother was not living. Both twins had identical, 
right torticollis with no palpable mass. One twin had a convergent squint 
of 15° which was not considered related to the torticollis by the ophthamo- 
logy consultant. They were treated by sectioning of the sterno-cleido- 
mastoid muscle and fascia and recovery was normal; neck movements with nor- 
mal range were present five months postoperatively. 
(Ed. note: This report adds weight to the congenital etiology of 
muscular torticollis.) 
Caffey (19) describes prenatal bowing and thickening of tubular bones, 
with multiple cutaneous dimples in arms and legs yrtiich is a congenital 
syndrome of mechanical origin. A small number of cases of this type have 
been reported in the literature to date. The author reports on three 
cases with symmetrical bowing of the femoral and humeral shafts but with 
deformities of the shafts of the tibia, radius and ulna. 
The shafts of these bones were thickened and bowed at the middle third. 
Large cutaneous dimples were present over the crest of the bowing in 
two cases which Dennis Browne in 1936 stated were intrauterine pressure . 
necrosis points. These were present at the end of the follow-up periods 
of 2i» and 30 months. The author believes that these three cases were the 
result of faulty intrauterine pressure and supports this hypothesis by 
pointing out that the children were entirely healthy but for these deformi- 
ties. All came from normal families; there was no evidence cf generalized 
or localized skeletal disease, and the bowing was characterized by thick- 
ening of cortex on the concave side of the curve. All cases improved 
spontaneously. However an osteotomy was performed on the tibia of the 
third case which was followed for a period of seven years. 
Nachlas (20) discusses common defects of the lower extremity in in- 
fants. The lower extremities of the newborn differ in their bony rela- 
tions from the adult. The main points of differences are lateral bowing of the legs, external rotation and flexion of the hips, and internal ro- 
tation of the legs and feet# The neck of the femur is at a more obtuse 
angle with the shaft. The stimulus of function associated with growth 
finally evolves the normal adult pattern. Any delay in growth or func- 
tion such as delayed walking from one cause or another will result in de- 
layed development of the adult pattern. One or many components of these 
infantile patterns may persist such as hallux varus, metatarsus varus, 
equinovarus, or internal rotation of the leg, External rotation deformi- 
ties are the result of contractures and developmental defects. The au- 
thor recommends corrective shoes and corrective adhesive tape for hallux 
varus deformities, and states that metatarsus varus may be overcome by 
manipulative stretching, the wearing of clubfoot shoes, rarely resorting 
to manipulation and casting. The treatment of the congenital clubfoot 
requires specialized treatment and should be referred to an orthopedist 
for care. The author states that an internal rotation deformity of tibia 
may be corrected by repeated daily derotation manipulation. A child may 
walk 7fith a clubfoot gait which is the result of stretched and painful 
medial foot ligaments which may be detected by the presence of tenderness 
and pain on attempted correction. This deformity is better treated by 
over-production of the deformity, the foot being held in inversion for a 
week or two, A knock knee with strained medial ligaments at the knee will 
also cause the child to walk in internal rotation as a protective mech- 
anism. 
The outward rotation deformities are seen as a congenital 
calcaneo-valgus. This deformity the author treats by adhesive tape cor- 
rection, rarely resorting to plaster casts. Occasionally an infant is 
seen which presents external rotation and flexion at the hip, the result 
of contraction of the external hip rotators. This deformity responds well 
to daily manipulative stretchings. The flat foot seen in the young child 
is usually the flexible type and is occasionally due to a short tendo 
Achillis after ambulation has begun. Inner shoe wedges are usually suc- 
cessful, occasionally an arch support needs to be added. The flat foot 
which is associated with knock knee is treated by manipulation, inner 
shoe wredges and occasionally braces. 
Clarke (21) discusses briefly the usual clinical patterns of osteo- 
genesis imperfecta tarda (Lobstein's disease) and presents a case report. 
The parents stated that they had noticed clicking in the child’s lower 
extremity joints since the age of eight months. They brought the child 
to the doctor when she failed to stand at twenty-two months of age. 
There was no familial history of brittle bones but the mother had blue 
sclera and was deaf. The brothers of the patient’s mother and in turn 
her mother were all deaf and some of these had the onset of their deaf- 
ness in early adult life. The physical examination revealed blue sclera, 
eroded teeth, the typical cranial deformity and marked laxity of the 
lower extremity joints. She was walking in braces. All clinical labora- 
tory tests were negative. There was no history of fractures. In the 
author’s discussion he points out the clinical and x-ray changes typical 
of this disease. He discusses the x-ray changes of the skeleton, the 
changes of the skull and face,i.e„ the broad temples, and the pointing 
outwards of the upper portion of the ears, which result in a small tri- 
angular shaped face. Blue sclera is apparently another inherited characteristic but not necessarily associated with brittle bones. Deaf- 
ness is due to otosclerosis appearing in early adult life when bone fra- 
gility is replaced by bone sclerosis. 
Giannini, Horreelli, and Greenberg (22) report a four and one-half 
year old Puerto Rican boy of dwarf stature due to an incomplete number of 
vertebral segments and a faulty development of the vertebral column. The 
mother had been treated for syphilis but repeated serological tests on the 
child were negative. X-ray studies of the boy revealed a normal skull and 
long bones. There was slight variation of contour of cervical vertebrae* 
There were only eight thoracic vertebrae with multiple abnormalities. There 
were seven ribs on one side, eight on the other, with a right dorsal scoli- 
osis. The lumbar spine was normal with slight variations but there were 
only three sacral centers present. The family history revealed no similar 
deformities. The authors present this abnormality as another cause of 
dwarfism. 
V/rist drop in the newborn due to radial nerve paralysis is rare. 
V/rist drop due to a fixed flexed posture of V>e wrist in utero is not too 
uncommon, Morgan (23) reports three cases, two due to nerve paralysis, 
one due to posture. The first case was in an infant delivered after a 
difficult four day labor which was terminated by forceps. The infant on 
delivery presented a depressed pressure ring around the trunk and both 
upoer arms with ecchymoses. The child was treated with cock-up wrist 
splints and there was return of radial nerve function in eight days; 
full recovery was present at the end of three months. The pressure con- 
striction ring about the lateral surface of both upper arms required 
three months to return to normal. The second case was unilateral and was 
present in an infant delivered by forceps. The patient had an obstetri- 
cal fracture of the humerus. Treatment consisted of splinting of the ex- 
tremity with, the elbow in flexion. One week following delivery a radial 
nerve paralysis developed art! a cock-up wrist splint was added. There 
was beginning return of function in three days and there was complete re- 
covery in seventeen days. The third case was also delivered by forceps 
with a positional wrist drop. The elbow, wrist and fingers were flexed, 
the forearm pronated, and the hand fitted into a depression behind the 
ear. Treatment consisted of cock-up wrist splint. The fingers extended 
at one week and the patient was fully recovered at the first postnatal 
visit. 
MacFarland (2U) discusses the less common orthopedic congenital de- 
The tibia is more often absent than the fibula. If the tibia is 
absent the fibula is usually rudimentary and the foot defective, although 
the tibial elements may be present. The treatment is amputation and it is 
advised to amputate after the child has established walking habits in a 
temporary prosthesis, amputation being deferred until after the third year. 
In congenital synostosis of the radius and ulna, the forearm is usu- 
ally fixed in moderate pronation although the position may be one less 
satisfactory for functional purposes. The synostosis usually occurs at 
the upper portion of the shafts. Surgery is generally unsuccessful be- 
cause of associated soft tissue changes. Successful resection of the synostosis is not usually followed by satisfactory supination and prona- 
tion. The child usually compensates very well for the deformity; how- 
ever if pronation is severe, an osteotomy is indicated to place the arm 
in a more functional position. 
In congenital lobster claw hand, two digits only are oresent, one 
resembling a thumb and the cleft extends to the carpals. The fingers 
usually are not straight but they conform to each other in apposition 
and palmar skin is present on the opposing surfaces, Surgery can offer 
no improvement in function. 
In congenital dorsal adduction of the 5th toes, these toes overlap- 
ping the neighboring i|th toes, lead to difficulty in shoe fitting and 
maceration of the skin between the toes. Amputation through the meta- 
tarsophalangeal joint is recommended. 
In congenital elevation of the scapula, there is a variable degree 
of deformity. There may be a very high or cervical scapula fixed with 
an omovertebralbone, with tilting of the head, and limitation of motion 
in the shoulder and neck. Surgery is disappointing. It is better re- 
served for the severe deformities and the recommended procedure is that 
of resection of the scapula. The milder cases improve with repeated 
stretchings and supervised active exercises. 
3randt (25) presents a case of arthrogryposis multiplex congenita 
anatomically appearing as a foetal spinal muscular atrophy. This con- 
genital disease was first described by Guerin in 1880. There followed 
several case reports between 1901 and 1937 in most instances described 
as multiple congenital contractures. In 1923 Stern renamed the deformity 
arthrogryposis multiplex congenita. Typically all four extremities are 
involved. The usual contractures are internal rotation of the shoulder, 
extension of the elbow, pronation of the forearm, flexion of the wrist, 
and flexion with ulnar deviation of fingers. The lower extremities com- 
monly present flexion and external rotation of the hips, extension or 
hyperextension of the knees and severe varus or equinovarus of the feet. 
Complete ankylosis of the joints is rare, the limitation being due to the 
contracture of the joint capsule and ligaments. The active range of mo- 
tion of the joints affected is decreased due to these contractures and 
to muscle changes most commonly affecting the deltoid and deep shoulder 
muscles, flexors of the thigh, flexors of forearm, and ektensors of the 
fingers and wrist. The muscle changes are essentially those of atrophy, 
fibrosis, and shortening. Luxation of joints is common. Other deformi- 
ties may be present and sometimes only the upper or the lower extremities 
are involved. The skeleton is usually normal, however, there may be an 
absence of the patella if the knee deformity is severe. The intellect 
is unimpaired. The child is frequently delivered abnormally because of 
the fixed abnormal position of the extremities. Occasionally a history 
of faint fetal movements is obtained. In hi collected cases, 25 were 
males, 22 females. 
The author presents a case of arthrogryposis which is the second case 
reported with post mortem studies of the central nervous system. The 
first case was reported by Price in 1933 who found evidence of inflamma- 
tion and degeneration of the central nervous system and concluded that there was an infectious etiology. The author's case is a three week old male 
infant who nursed ineffectively and when first seen, was markedly under- 
nourished and dehydrated. There was internal rotation of the shoulders, 
pronation of the forearms, extension of the elbows, flexion of the wrists, 
with ulnar deviation and fixation of the thumbs in the palms. No passive 
correction was possible. Marked muscle atrophy was present; the latissimus 
dorsi was short and tight on both sides and the shoulders could be abducted 
to only U5 degrees. The hips were flexed and abducted, the knees flexed 
and there was varus deformity of the feet. There were no paloable dorsal 
spine muscles, there was atrophy of the cervical spine muscles and there 
was a fixed opisthotonus posture contracture. The facial muscles were 
atrophied, the child could not close his mouth. The eye and tongue muscles 
functioned normally. The x-rays revealed no skeletal defects. Laboratory 
tests were all normal and the infant was judged normally intelligent. 
The child died at the age of seven weeks and post mortem examination 
revealed no abnormalities of the visceral organs. Biopsy of the quadri- 
ceps muscle revealed considerable increase of fascicular connective tis- 
sue, extreme atrophy of the muscle cells which were seen as areas rich 
in nuclei with degenerated threads of muscle tissue. No inflammatory 
areas were discovered or areas of vascular changes. There was no evidence 
of muscle degenerative changes. Studies of the central nervous system re- 
vealed lower motor neuron degenerative changes. There were profound 
changes seen in the anterior horn cells with severe degeneration of the 
cells with sclerosis and vacuolation, and numerous empty spaces previously 
occupied by motor cells. There were scattered normal cells seen throughout 
the tissue. The histological diagnosis was a degenerative central nervous 
system lesion, with secondary muscle changes. 
The author postulates the etiology of arthrogryposis, based upon this 
study, to be a lower motor neuron degenerative disease occurring early in 
fetal life, fie reasons that the paralysis occurring early in fetal life 
before the muscles are active enough to move the various affected joints 
accounts for the severe contractures present. This pathology he holds to 
be allied to the Werdnig-Hoffman1s spinal muscular atrophy which he be- 
lieves occurs later in fetal life after fetal motion is active and range 
of motion at the joints is thus actively established before the onset of 
the paralysis. Other etiological theories are comprehensively discussed. 
(Ed. note: This is a well presented study of this comparatively un- 
common though severely crippling congenital deformity. The author's de- 
ductions as to etiology are logical and it is hoped that this report will 
offer further stimulus to additional studies of post mortem material. It 
is possible that more careful prenatal histories will disclose the rela- 
tionship of this disease to prenatal maternal infections.) 
Sear (26) reports a case of Sngelmann's disease; osteopathia hyper- 
ostotica sclerotisans multiplex infantilis. This is the rarest form of 
the congenital condensing osteodystrophies. The case reported represents 
the second appearing in the literature at the time of publication, A ten 
year old boy presented x-ray evidence of symmetrical bone condensation 
mainly at the central portions of the shafts of the long bones associated 
with thickening. This was the characteristic change in the case reported by Engelmann in 1929. The bone changes were more marked in the clavicles, 
forearm bones, femora, and tibiae. There was also condensation of the ba- 
silar skull and frontal bone associated with thickening and in addition an 
area of condensation in the iliac bones and the first cervical vertebrae. 
Clinical laboratory tests were normal but for slight hypocalcemia. Biopsy 
studies were inconclusive. 
Andreasen (2?) reports two cases of congenital absence of the humeral 
head, one unilateral and one bilateral. Radiographs and photographs are 
shown. There was limitation of abduction and rotation at the shoulder* 
Review of the literature revealed six other reported cases. The author dis- 
cusses the embryological aspects of this deformity concluding the defect 
to be the result of a developmental accident occurring at the stage of 
separation of the articular rudiments during embryological development. 
Vastine II, Vastine and Arango (28) report myositis ossificans pro- 
gressiva in horaozygotic twins. This represents the first reported case of 
myositis ossificans occuring in identical twins and lends weight to the 
genetic etiological theory of this condition. The authors briefly dis- 
cuss the other evidence of the hereditary nature of this disease and point 
out that the condition is an ossification of connective tissue rather than 
muscle tissue• They also discuss the clinical manifestations, x-ray 
changes, and pathology of the disease. The twin girls were ten years of 
age when first seen, complaining of stiff neck and stiffness in other 
joints. Both had well advanced manifestations at this time, with limita- 
tion of motion of the cervical spine, and upper extremity joints; both had 
short left great toes. The family history was negative. Both girls were 
studied roentgenologically at the age of sixteen, revealing a similar pat- 
tern of ossification of soft tissues in the posterior cervical region, 
posterior thoracic region, along the lumbar muscles, and about the hips. 
In addition there was found to be fusion of the great toe phalanges and 
deformity of the distal heads of the first metatarsals. 
Gordon, Schecter, Perlman (29) report a case with multiple congenital 
deformities. Tbe case is presented as having congenital skeletal deformi- 
ties not previously related in any clinical syndrome. A thirteen year old 
’white female with no familial history of deformities had been treated 
since the age of fourteen months with thyroid extract. The outstanding 
skeletal changes discovered were multiple luxations, involving both pat- 
ellae and both radio-humeral joints, and multiple fusions of the small 
bones, and of the cervical, and lumbar vertebrae. 
The case of a thirty-seven year old male with flattening of the base 
of the skull, vertebral chondrodystrophy and osteoporosis and many other 
changes is reported by Hajdu, and Kauntze (30). There was no family his- 
tory of deformities. The skull was clinically broadened with decrease of 
the vertical height and flattening. The palate was high and narrow, the 
jaw prominent and the neck was short. He had a moderate valgus deformity 
of both knees and elbows and the fingers were short and bulbous. Conduc- 
tion deafness was present. Clinical laboratory tests were within normal 
limits. X-ray studies revealed a marked basilar impression with broaden- 
ing of the skull, patent suture lines and small facial bones. The verte- 
bral bodies were osteoporotic and biconcave with collapse and scoliosis resulting. The terminal phalanges of the fingers were represented by a 
visible proximal epiphysis and the visible tip of the shortened phalanx. 
There was also some deformity of the metacarpal heads, radio-carpal arti- 
culations, carpal bones, distal portions of the forearm bones, and severe 
osteoporosis of the phalanges of the right foot with findings of the ter- 
minal phalanges resembling those of the fingers. The authors conclude 
that the peripheral lesions are the result of failure of ossification of 
pre-formed cartilage. The vertebral osteoporosis is not explained. 
DeVito (31) reports a case of osteogenesis imperfecta in a seventeen 
day old white male who was brought to medical attention because of bowing 
of the legs and softness of the cranium noticed by the parents. The pre- 
natal and delivery history were normal and the child’s general condition 
was good. The family history was negative. Physical examination revealed 
softening of the cranium, most narked over the occipital area, and widely 
opened sutures. There was a blue tinge to the sclera. The anterior borders 
of both tibiae were irregular. X-ray studies revealed deficient calcifi- 
cation of the skull and bulging fontanelles. There was a tendency of the 
cervical spine to prolapse into the skull. The spinous process of C-2 was 
fractured along with evidence of fractures of an acromial process, scapula, 
femur and ulna. There was congenital dislocation of both hips, bilateral 
clubfoot deformity, anterior bowing of both lower extremities and multiple 
fractures of the ribs with deformity. The patient was discharged from the 
hospital and died suddenly twenty-four hours later of an acute atelectasis. 
At autopsy the following pertinent findings were reported: increased occipito- 
bregmatic skull diameter, saddle nose, blue sclera, short neck, and short 
bowed extremities. The fontanelles were large and brain convolutions were 
flattened. The cartilaginous bone presented irregular islands of calcifi- 
cation, more marked in tho skull; the long bones crushed between the fingers 
like corrugated paper and cut surfaces bled readily. The long bones pre- 
sented irregular areas of excess callus from healing fractures and platy- 
basia of the skullwas present. 
Boyd and Fox (32) give a follow-up study and report of seven cases of 
congenital pseudarthrosis after massive bone grafting, four of them ori- 
ginally reported in This article is less optimistic than the first 
report as to the results obtained, and the authors conclude that adequate 
protection is necessary until the bone has developed a new' medullary canal 
and the tibia compares in size and strength to the normal, this period usu- 
ally extending past puberty. The occurrence of refracture, recurrent scle- 
rosis about the fracture site, or narrowing of a previously reformed med- 
ullary canal is felt to be an indication for reinforcement grafting. Bony 
union occurred after bone grafting but refracture was prone to occur, and 
union is again as difficult to secure as originally. There wras the same 
pattern of bone re-absorption from unknown cause following the refracture. 
Neurofibromata were not found at surgery. 
The seven cases are presented in some detail followed over a period 
of three to twenty-two years, and each case is discussed. One case came 
to amputation. The authors believe that grafting should be carried out 
early, at three to five years. Donor bone from a parent was often used 
and complete and prolonged immobilization was necessary, four to six 
months in a cast, followed by brace protection usually until after puberty. Hauser (33) states that cast treatment of the congenital clubfoot 
is extremely difficult before the age of three months and that develop- 
ment of the foot and leg is jeopardized by this form of treatment. He 
advocates early institution of treatment and describes in detail the 
technique for utilizing cohesive bandage (which adheres to itself but not 
to the skin), component of the deformity is corrected with adhesive 
strips overlying a basic encircling bandage of leg and foot, and the com- 
pleted corrective dressing is again completely covered with another layer 
of this cohesive bandage. Additional bandage is added daily obtaining 
additional correction during the first week, the entire dressing changed 
then, at two or three week intervals. Over-correction is maintained un- 
til walking begins. In six of his cases subcutaneous achilles tenotomy 
was necessary and three had plantar fasciotomies. Outer shoe wedges with 
bracing in abduction and external rotation are started when weight bear- 
ing begins. Seventy cases thus treated led to excellent correction, how- 
ever there were tiiree who required more correction at four to six years, 
and five in which the deformities were considered "congenital anomalies." 
According to Goldstein (3U) many combinations of congenital fusions 
of the carpus and tarsus are possible, the most common being congenital 
fusions of the lunate and triquetrum. Sixteen cases were found reported 
in literature. The fusions are characterized by true bony continuity with- 
out evidence of a pathological process which might have caused fusion, and 
Jbhe presence of a line representing the intended joint. One case is re- 
ported in a U2 year old Jewish female as an incidental x-ray finding. 
There have been four cases of congenital fusion of the capitate and lesser 
multangular reported and the author adds another case, a year old Jewess 
with this anomaly in both wrists. 
The many possible combinations of congenital fusion of the tarsal 
bones are discussed and the literature summarized. 
One additional case of symmetrical humeral-ulnar synostosis in a 
3-7/12 year old Jewish boy is reported. There is an associated fusion of 
all the visible carpal bones, synostoses of toe and finger phalanges, and 
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25* Brandt, S,: Case of arthrogryposis multiplex congenita anatomically 
appearing as foetal spinal muscular atrophv, Acta Paediat., 31*: 365- 
381, Nov. 191*7 
26. Sear, H. R.: Engelmann’s disease; osteopathia hyperostotica sclero- 
tisans multiplex infantilis; report of case, Brit. J. Radiol., 21t 
236-21*1, May 191*8 
27. Andreasen, A. T.: Congenital absence of humeral head; report of two 
cases, J. Bone & Joint Surg., 30B: 333-337, May 191*8 
28. Vastine, J. H., II, Vastine, M. r. and Arango, 0.: Myositis ossifi- 
cans progressiva in horaozygotic twins. Am. J. Roentgenol., 59: 20l*- 
212, Feb. 191*8 29. Gordon, S. J., Schecter, N. and Perlman, A. V;.: Multiple congenital 
malformations of skeletal system; case report. Am. J. Roentgenol,, 
o9: S33-53B, April 19i;8 
30. Hajdu, N. and Kauntzs, R.s Cranio-skeletal dysplasia, Brit. J, Radiol., 
21: i|2-U3, Jan. 19^8 
31. DeVito, A. T.: Osteogenesis imperfecta congenita, Clin. Proc. Child. 
Hosp., flash,, U: 208-212, July 19)48 
32. Boyd, H. 3. and Fox, K. V.r.; Congenital pseudarthrosis; follow-up 
study after massive bone grafting, J. Bone & Joint Surg., 30A: 27U- 
283, Apr. 19a8 
33* Mauser, S. D. V/.: Cohesive bandage for clubfoot in newborn infants, 
J. A. M. A., 138: 19-22, Sept. U, 19U8 
3ii. Goldstein, R,: Congenital synostosis of carpal and tarsal bones and 
ankylosis cubiti, Radiol. Clin., 17: 66-73> Mar. 19U8 
19 SECTION 2 
DISEASES OF GROWING AND ADULT BONE 
Prepared by Robert W. Boal, Col., M.C., USA 
Growth of Bone 
Elgenmark (1) has compiled tables to show the normal ossific center 
development. These tables which indicate all the ossification centers 
(68 in number) on one side of the body, show that the appearance of other 
centers cannot be predicted from the date of appearance of a single center. 
In the article under review he compares his previously determined nor- 
mals with the number of epiphyseal centers at a given height and age in 
several developmental diseases. The series is short and he feels final con- 
clusions cannot be drawn. 
In evaluating a case, distinction must be made between males and 
females, for girls show a greater number of centers, particularly at the 
height of 70 cm. and at the age of 10 months. The number of centers is also 
more closely correlated with height than with age. The tables can be uti- 
lized to determine whether or not body development is normal. In breast- 
fed infants usually there are no changes before four months. No case of 
mongolism had delayed skeletal development, cases of cryptorchism showed 
marked retardation and a hermaphrodite showed development more closely resem- 
bling a female. 
The author concluded that by utilizing his tables one could gain some 
knowledge of disturbances in skeletal growth as well as the degree of de- 
velopment. 
Haas (2) in a series of very significant experiments on dogs, observed 
the effects of various combinations of metal staples across epiphyseal 
plates. His results indicate that wires or staples placed unilaterally 
across the epiphyseal cartilaginous plate will arrest longitudinal growth 
on the side of insertion and also on the opposite side of the same plate 
to a lesser degree. Consequently loss in length of the bone may occur. In 
addition, he showed that growth is active after temporary retardation, but 
is less than on the normal side. Some of the plates showed premature closure 
after temporary retardation. 
Ross, (3) in a study of longitudinal growth in conditions involving 
prolonged disability of the lower extremity, found that growth arrest may 
result at the knee. He presents thirteen patients, of which nine were from 
a group of 92 cases of tuberculosis of the hip (10$). 
It is his impression that the atrophy of disuse leads to partial 
degeneration of the cartilage which is in turn followed by complete degenera- 
tion with subsequent bony bridging. The latter he feels is due to some 
secondary factor, such as the abnormal stresses of a faulty gait. Fuller and Woolf, (U) of the Physical Development Centre report "a 
high incidence o-TTeg shortening with resultant scoliosis among recruits 
sent to the centre for a remedial course for various postural or other 
defects". They give no statistics because the group is not a cross section 
of the British Army, The recruits were mostly 171 - 18| years of age. 
The shortening varied from l/k to 1-l/U inches. Remarkably few gave history 
of symptoms, injury, or poliomyelitis. Shortening of l/h-l/2 inch was com- 
pensated for by raising the heel. No lifts over l/2 inch were given. In 
discrepancies over 1-2 inch, the affected side lowered a corresponding 
amount• 
Rickets; 
Sydow (5) reports the results of his observations and studies of the 
serum calcium, inorganic phosphorus and alkaline phosphatase in premature 
and full term infants when fed on formulas of breast milk and cows milk, 
with and without the addition of Vitamin D. He found that at birth the 
serum phosphatase in the premature, was about 1-J times as high as the full 
term infants, and the serum calcium about 1 mg;t lower. The serum phosphorus 
was the same. In the premature infants fed on breast milk the phosphatase 
remained high even with the addition of Vitamin D, and somewhat lower when 
they were given only cows milk. The addition of Vitamin D to the cows 
milk brought the values to normal. Premature infants fed on breast milk 
showed a considerable lower serum phosphorus level than the normal. The 
addition of Vitamin D caused no change while the addition of cows milk 
produced some improvement. Vitamin D added to a cows milk formula brought 
the levels near normal. In studying the serum calcium levels he found that 
it was low in premature infants fed a formula of human milk or cows milk 
but the addition of Vitamin D improved the serum calcium level. Roentgen 
findings of rickets were observed as early as the Hith day, and neither the 
addition of cows milk or Vitamin D could with certainty prevent the devel- 
opment, although roentgen changes were noted more infrequently in the sub- 
ject fed cows milk. Histologic changes typical of rickets were found in 
several of the cases* 
Man, (6) reports the results of experiments to find the factor causing 
retarcleci growth in chickens, when fed on a diet containing 2% dried yeast. 
They looked for a specific phytase inhibiting substance, but could not 
confirm its presence in yeast. They attribute the retardation of growth 
by yeast to the inorganic phosphate. 
Portal, (7) discusses the use of various exercises to correct bony 
deformities by strengthening the weak muscles that caused or contributed 
to the deformity. The author makes suggestions for recreational activities 
that may be of value in promoting the specific remedial exercises. 
Infantile Cortical Hyperostosis 
Shuman, (8) reports a case of infantile cortical hyperostosis in a 
I4-month old child. This illness is characterized by fever; irritability; 
anemia; brawny, facial edema; x-ray evidence of hyperostosis of the manible, 
ribs, and clavicle; and unaltered growth and development of the patient. 
The etiology is undetermined, and the course is unaffected by penicillin, 
sulfadiazine, anthistaminics and elimination diet. Zeben, (9) presents three cases of infantile cortical hyperostoses, 
a disease first reported by Caffey in 1939* The only symptom was swelling 
of the lower legs. X-ray showed extreme thickening of the periosteum of 
the shafts of the bones of the leg, as well as along parts of the skeleton 
not associated with swelling. These three cases occurred within the same 
family and all showed forward curvature of the tibia. 
Cartilage 
Gordon, Perlman and Schecter (10) report a case of diffuse inflammation 
of cartilaginous tissues of the Tody, They were unable to find its counter- 
part in American or foreign literature. The condition occurred in a 3k year 
negress and manifested itself with cough, dyspnea, swelling and tenderness 
of knee, ankle and ears. The patient gave a negative venereal history. 
Biopsy of articular and nonarticular cartilage was reported by various 
authorities as "diffuse degenerative change in cartilage", "unable to offer 
any interpretation" and "rheumatoid arthritis". 
Swenson, (11) has reviewed the literature of osteochondritis dissecans 
and osteochondromatosis• He concludes that trauma plays a definite role 
in producing non-infectious sequestration of subchondral bone from an ar- 
ticular surface with deficient nerve and vascular supply in the former. 
It is apparently a predisposing factor also in initiating the metaplastic 
process of synovial chondrification in osteochondromatosis. He points out 
that the bones and Joints begin their differentiation from a single type 
of mesenchyme and its derivatives may retain the power of cartilage forma- 
tion throughout life. Thus, with repeated traumatic irritation, hyperplasia 
of the synovial membrane may occur and metaplasia supervene as an individual 
reaction to form beads of cartilage in the relatively undifferentiated con- 
nective tissue of the villous synovial membrane. The author adds ten cases 
that were treated by surgery with satisfactory results. He feels this is 
the treatment of choice. 
Osteopetrosis 
Fairbank, (12) reviews the clinical features of Albers-Schonberg's 
disease (Marble Bones), pointing out that the syndrome is characterized by 
abnormal density of bones, with or without fragility, a strong tendency to 
anemia which may be severe or fatal, and optic atrophy. There may be inter- 
missions, remissions, or complete cessation of the developmental error be- 
fore growth ceases. The petrosed bone is white-gray on section. X-ray 
usually makes the diagnosis, but heavy metal poisoning should not be con- 
fused. 
A report of a single case of marble bones or Albers-Schonberg's disease 
is made by Rugg-Gunn, (13)* The patient was a 23 year old female who was 
admitted because of complaints of sinus trouble. X-rays revealed some sort 
of generalized bone disease, (no description is given). The family history 
was irrelevant except for vague rheumatoid symptoms in the mother. The 
patient showed only slight bossing of the frontal bones. The serology was 
negative. The serum calcium was l£ mg. per 100 cc. and the serum phosphorus 
was lt.9*per cent. In the discussion, Albers-Schonberg's original case is 
described. No members of the patient's family were available for study. 
She was essentially symptom-free. 
* rag. per cent Os te opolkllos is 
In the fourth section of the Atlas of General Affections of the Skele- 
ton, Fairbank, (Hi) presents the subject of osteopoikilosis or Osteopathia 
Condensans Disseminata, The condition is rare and is manifested by multiple 
dense spots in many bones* It tends to be familial and affects males twice 
as often as females* A congenital etiology is accredited by some, but some 
cases show spots in bones that are not ossified until after birth* There 
are no significant blood changes. The x-rays show dense spots, varying from 
2-10 mm*, which parallel the long axis of the bone and are most conmon in 
the epiphyses* In most cases, they appear in all bones except the skull, 
ribs and vertebra* The course tends to be uneventful with little or no 
change in the x-ray over the years* Occasional cases are associated with 
dermatofibrosis lenticularis disseminata* 
Melorheos teals 
Fairbank, reviews the h7 cases that have been reported of this 
rare condition, and includes several case reports with reproduction of 
radiographs* The distinguishing features of this disease, which differs 
from generalized osteopetrosis or ‘'marble bones" are: (1) changes confined 
to the bones of one limb; (2) the distorted outline of an affected bone; 
(3) pain, occasionally severe, sometimes unbearable; and (U) limitations 
of movement in the joints formed by the affected bones* None of these 
features are invariably present. It is observed in both sexes but is more 
frequent in the male* The age incidence is 5 to 5U years, with 75% under 
36. It probably begins in childhood or in fetal life. Pain is the most 
frequent symptom. Shortening and deformity of bone occur* Scleroderma 
appears as a complication* Radiographs show the dense, structureless ap- 
pearance of "marble bones" in parts or the whole of the bone; the "flow" 
of dense streaks and blotches may be interrupted or continuous and suggests 
the flow of candle-grease down the limb. The bone changes are progressive. 
Available histological reports show sclerosing areas, with compact over- 
crowding of lamellae arranged in a bizzare manner, with an interlacing pat- 
tern of immature and adult bone* 
Metaphyseal Dysostosis 
Fairbank, (16) describes the clinical features as well as radiographic 
features and pathology of the only case of metaphyseal dysostosis reported 
in literature * This condition is differentiated radiographically from 
dyschqdroplasia by the absence of the columnar arrangement of the carti- 
laginous metaphysis and of mottling of the epiphysis, either partly or wholly. 
The spots of calcification and ossification in the metaphysis vary in size, 
shape, and density, and they differ from the circular dense spots which are 
seen in the "healing stage" of dyschondroplasia. 
Osteoporosis 
Albright, (17) presents a classic discussion of osteoporosis, which 
should be read by all, whether in the field of surgery or medicine. He has 
come to the following conclusionss"(l) Osteoporosis is defined as the 
category of decreased bone mass where the disturbance is a failure of the 
osteoblasts to lay down bone matrix. (2) Three, factors which influence 
osteoplastic activity ares (a) steroidal hormones, (b) mechanical stresses and strains, and (c) nitrogenous building blocks. (3) In respect to bone 
matrix, the steroids can be divided into anabolic steroids (estrogens and 
androgens), and anti-anabolic steroids (adrenal cortical ,!SM hormones), 
and anabolically-inert steroids (progesterone). (U) The age of entrance 
of adrenal cortical ”N" hormone on the scene is termed "adrenarche"; the 
age of exit, the "adrenopause”• The adrenarche is usually synchronous with 
the menarche; the adrenopause is normally considerable later than the 
menopause. The adrenal cortical HS” hormone is produced at the same level 
during childhood, age of sexual maturity, and senility. (£) The osteopor- 
osis of old age is partly to be attributed to the loss of gonodal hormones 
and the adrenal-cortical "N” hormone and responds to estrogen and testos- 
terone therapy. (6) The osteoporosis of the post-menopausal state is to 
be attributed to the decrease in estrogen production following the meno- 
pause and responds to estrogen and testosterone therapy. (7) The osteopor- 
osis in Cushing's syndrome and in the adaptation syndrome of Selye is to 
be attributed to an excess of the anti-anabolic adrenal cortical "S" hormone 
and responds to testosterone therapy. (8) The adrenocorticotrophic hormone, 
by releasing T,S” hormone from the adrenal cortices, likewise produces osteo- 
porosis; the effects of A.C.T.H. on panhypopituitarism is demonstrated. 
(9) Evidence is presented to suggest that the effect of testosterone in 
stimulating anabolism may be partly, but probably not wholly, due to its 
property of causing decreased production of the adrenal cortical anti- 
anabolic "S'* hormone rather than entirely to a direct anabolic property of 
its own. (10) The production of bone matrix is undoubtedly influenced by 
the availability of certain nitrogenous substances; evidence is presented 
which suggests that the height of the serum albumin is an important factor.” 
Kesson, Morris, and McCutcheon, (18) have made an excellent attempt 
to determine the etiology of generalized osteoporosis in the aged, in which 
they reviewed a series of 80 patients over UO years of age drawn from the 
poor sections of the population of Glasgow. These findings were compared 
with radiographs taken of the spine during the years of 1939-19iil of 22? 
patients over UO years of age from the same strata of the community. They 
have stated that when the cause of osteoporosis is known, and when the cause 
can be removed, the condition can be cured. As an example, the administra- 
tion of Vitamin D with a generous supply of calcium to the patient with 
osteomalacia leads to rapid recalcification of the bone. The cause of the 
senile osteoporosis has not yet been determined accurately, but by their 
investigation they feel that endocrine disturbance, arteriosclerosis, and 
anemia can be excluded; but the lack of exercise may play a minor part in 
the etiology. Also, that reduced intake of minerals over a long period of 
time was probably an important factor, although it was not possible to prove 
by radiographic evidence of calcium deposition in the rarefied skeleton 
with a rich supply or rich diet in calcium and phosphorus. They thought 
that a very lengthy period was required to restore it. Although no improve- 
ment was effected radiographically in the patients treated with a high 
intake of minerals for a period of fifteen months, no increase of osteopor- 
osis was noted. Thus, they felt that it was possible to prevent further 
decalcification and the occurrence of complications by administration of 
a high diet rich in calcium and phosphorus. Vitamin ”D” was not shown to 
be concerned in the etiology, but they advised the administration in moderate 
doses. Lauber, V/eber and Greenfield (19) report a case of idiopathic extreme 
osteoporosis involving the spinal column and thoracic cage with collapse 
of the front of the chest* In association with this, there was considerable 
anemia and, as with similar cases recorded in the literature of this subject, 
no cause was discovered and all treatment was unavailing. This case again 
reveals that the treatment of this condition will be rational only after 
the chemistry of bone metabolism is better understood. 
Albright1s Disease 
In 1937f Albright, Butler, Hampton and Smith described a syndrome now 
known as Albright1s disease. This is characterized by the presence of mul- 
tiple bone lesions, areas of skin pigmentation, and precocious puberty in 
females. They suggested the term Mosteitis fibrosa disseminata” to dis- 
tinguish the skeletal changes in this syndrome from those associated with 
hyperparathyroidism. The name "Polyostotic fibrous dysplasia” was intro- 
duced one year later by Lichenstein and later modified to fibrous dysplasia 
McMahon (20) reviews a case in which there are three separate and distinct 
bone changes: (1) Fibrous dysplasia, involving every bone in the body, 
(2) a disturbance in the epiphyseal growth involving both bone and carti- 
lage, and (3) wide spread bony atrophy. Of the three changes, fibrous 
dysplasia was by far the most striking. 
Aegerter, (21) finds that neurofibromatosis is a condition characterized 
by multiple nodules of fibroblastic hyperplasia of nerve supportive tissue. 
It is associated with scoliosis, asymmetric hypertrophy and focal lesions 
usually misdiagnosed as bone cysts. It or its associated conditions 
accompany congenital pseudarthrosis and fibrous dysplasia in many cases. 
It is well shown that congenital pseudarthrosis is not a result of neurofi- 
broma. It is suggested that neurofibromatosis and fibrous dysplasia are 
caused by defective mesenchymal germ plasm. 
Gaucher1s Disease 
Windholz and Foster (22' point out that in Gaucher’s disease there are 
frequent signs of bone formation in the medullary cavity and report two 
cases. The new bone formation is not excessive and occurs not only in bone 
structures adjoining absorptive changes, but also in parts of the medullary 
cavity where no bone destruction is evident. In- the two cases reported, 
bone cylinders occupied the peripheral portions of the proximal two-thirds 
of the medullary cavity. The bone tissue is laid down in the intercellular 
fibrous structures of Gaucher proliferation as a product of direct metapla- 
sia of collagenous fibers, hence is present only in advanced stages of the 
disease process. Roentgen signs of pathological ossification occurring in 
areas situated about absorptive lesions involving simultaneously more remote 
areas of the medullary cavity, in which no destructive changes are evident, 
may be of diagnostic significance in Gaucher’s disease. 
Hand-Schuller-Christian Syndrome 
An article by Smyth. (23) presents observations of the syndrome of 
membranous bone involvement, diabetes insipidus, and exophthalmos, called 
Hand-Schuller-Christian disease. Hand ascribed the etiology to tuberculosis, 
but later suggested a neoplastic, benign, myxomatous condition. The presence 
of diabetes insipidus pointed to the pituitary and emphasized the endocrine 
factor. Warthin’s biopsy studies called attention to the accumulation of 
foam cells in the affected area and called attention to the cholesterol deposition, suggesting an abnormality of fat metabolism. Further studies 
indicate that neither the originally described triad nor the foam cell 
found on section is an entirely reliable diagnostic aid, Vvallgren, Faber 
and Mallory suggest that Letterer-Siwe’s disease occuring in two-year olds, 
Schuller-Ghristian disease occurring in older children, and eosinophilic 
granuloma of adults are manifestations of the same general process. The 
latter have suggested an infectious, possibly virus, etiology. Best results 
in treatment have been a combination of excision and x-ray. 
Leontiasis Ossium 
Way, (2k) reports the case of leontiasis ossium in a spinster who died 
in 19Wat the age of 73# At 20, a bicuspid tooth was filled, following 
which she developed a hard swelling in the gum above the tooth and similar 
changes in the cheek. Dental treatment followed, but the swelling spread 
to the other cheek and to the frontal region. In 1939 she had a transient 
hemiplegia associated with a blood pressure of 222-/95* Four months before 
her death she lost muscular control and became intensely deaf. The article 
includes a picture and radiographs of the lion-like head. The condition 
caused little inconvenience to the patient's health. The base of the skull 
was involved in this case but the mandible was not. The patient had colds 
and the author states that this and the dryness of her nose suggests that 
the mucosa lining the sinuses is the major source of nasal secretion. 
Osgood-Schlatter1s Disease 
In an attempt to determine the true nature of Osgood-Schlatter’s dis- 
ease, Hughes, (25) reviews the normal anatomical and radiological features 
of the tibia! tuberosity in varying stages of its development. His investi- 
gation through careful roentgenological study in twenty cases shows clearly 
that the clinical features are almost certainly due to pathological changes 
primarily within the ligamentum patellae rather than in the apophysis and 
the ossification at the sito of insertion is accounted for by the partial 
tearing of the ligamentum from the bone. The insertion of this tendon at 
the smooth portion of the tuberosity is not as firm as it is in the groove, 
and if the ossification is higher than the ligamentum, it may be due to an 
extension of an osteoplastic reaction or to a metaplasia of the fibroblasts. 
In any case it seems the etiology or the initiating stimulus was injury to 
the ligamentum directly or indirectly. Trauma was believed by both Osgood 
and Schlatter to be the cause of a painful this author feels 
the same. The pathology which the trauma produces is not clearly understood. 
It is believed to cause separation of the tongue-like epiphysis from the 
diaphysis by some. Others believe the injury interferes with the blood 
supply and so causes an aseptic necrosis of the apophysis and still others 
believe there is a disorganization of the apophyseal centers or actual 
avulsion of a fragment of bone. The first radiological sign of this dis- 
ease is thickening of the ligamentum patellae. Studies by Hughes indicate 
the condition is the same type of pathology as myositis ossificans, Hughes 
states also that the appearance of the fragmentation is a normal stage in 
the apophyseal development. His conclusion in the study of 20 cases of 
Osgood-Schlatter’s disease is that the disease is primarily an intra- 
ligamentus rather than epiphyseal condition and the disease is a tendonitis 
rather than an epiphysitis. Kridelbaugh and Wyman (26) report 13 cases of Osgood-Schlatier’s dis- 
ease seen~in a period of nine weeks at a large Naval Recruit Training Cen- 
ter. In this study they suggest a classification of three tyoes: (1) 
Tibial tubercle epiphyseolysis; (2) Tibial tubercle fragmentation (a) with 
and (b) without, epiphyseolysis; and (3) Tibial tubercle necrosis (a) with 
and (b) without epiphyseolysis. They treated all their cases conservatively 
with thigh cross-strapping to relieve the pull of the quadriceps tendon 
upon the tubercle. The etiology was ascribed to trauma, aggravated by exer- 
cise carried on during training. 
Osteogenesis Imperfecta 
Fairbank and Baker (2?) discuss hyperplastic callus formation, with 
or 'of a fracture in osteogenesis imperfecta. In 19U3 
Brailsford suggested that the subperiosteal hemorrhage which at times occurs 
in osteogenesis imperfecta, might be due to scurvy. The authors studied 
eight cases, six of whom were osteogenesis imperfecta and two were not 
definite but were suggestive. In these there was formation of intensely 
calcified local callus or excessive formation of ossified callus around the 
shaft;"formation of bony excrescences on the shafts of long bones, especially 
on the interosseous borders; and all with little or no evidence of fractures. 
This excessive callus is often very irregular and not the usual fusiform 
type as often seen in fractures, 'When there was a fracture present with 
this excessive callus formation, this formation extended far beyond the 
fracture. This enlarged portion often was open meshed or coarsely cancel- 
lous bone. Some of the fractures in these cases heal normally with the 
usual amount of callus formation. This excessive formation of periosteal 
bone occurred most in the femur and humerus. Bony excrescences were found 
most often in the radius and ulna and usually at the interosseous side. 
They might be rounded or spicular in shape. These findings were first 
found in children from the age of 1 to l£ years. There were curvatures of 
the long bones in all these cases and malformations of the other bones. 
They had osteoporosis and the spine often showed bi-concave vertebrae. 
These complications occurred at times while the patient was in the hospital 
and with adequate diet and vitamin C, The swelling in some of the cases 
was so rapid and great that it was suggestive of a sarcoma and a biopsy 
was done. The microscopic examination showed chondroid or semicartilaginous 
tissue which is a transition between fibrous, mucoid and cartilaginous tis- 
sue, A section through the tissue from the outside in, shows the dissolu- 
tion of the muscles and connective tissue to that of calcified cancellous 
tissue on the inside. The authors feel that there is a definite relation- 
ship between this excessive callus formation and osteogenesis imperfecta. 
It is more common in the femur than in other bones. They do not agree with 
Brailsford as they do not think that any of these cases showed any evidence 
of scurvy. The subperiosteal hemorrhage in scurvy shows a smooth enlarge- 
ment and the above are often very irregular. In scurvy the shadows dis- 
appear but these do not. These cases have only in one case shown evidence 
of hemorrhage in the skin or gums. In traumatic myositis ossificans there 
is not this extensive callus formation. In these cases trauma was the only 
possible cause that they could detect. 
Fairbank (28) gives a very excellent discussion of osteogenesis imper- 
fecta and presents several cases. The condition is characterized by fragil- 
ity of the skeletal bones. The cause is unknown. He groups the cases into 
■* ,often with permanent enlargement of the shaft; 
27 pre-natal and post-natal, but there is no clear cut division, the fractures 
occurring earlier in the former. The prenatal is more severe and these often 
die early. Osteogenesis tarda is the term applied to the late cases. Hered- 
ity and familial influences are apparent in a minority of the cases. It 
may be inherited through either parent. Both sexes are involved, the female 
a little more frequently. Blue sclera is common especially in the post- 
natal group. Otosclerosis may occur in those who live to the third decade 
but has been reported as early as the 13th year. Bickel found deafness in 
of the hereditary and 17$ of the non-hereditary cases. In adults with 
blue sclerotics 60$ develop otosclerosis with or without bone fragility. 
Laxity of joints is not uncommon in the family. Osteomalacia with bending 
of the bones may be present and is striking in the pelvis. The number of 
the fractures varies markedly, some as high as 100. Refracture may occur 
several times but may be due to osteoporosis of disuse. Most severe cases 
are dwarfed and this is accentuated by the curvature of the legs and spine. 
Scoliosis may be severe. The skull is broad, with prominent parietal and 
occipital bones. The ears are often directed down and out. The teeth may 
be poorly calcified and waxy. The intelligence is average. The musculature 
is extremely weak but much of it may be due to the fractures and deformities. 
There is a tendency for improvement. The main pathology is the imperfect 
formation and imperfect calcification of the bone trabeculae. Islands of 
cartilage are seen, especially under the periosteum. The periosteum is thick- 
ened and there is a failure of formation of the normal shell of cortical 
fjone. The medullary contents may be fibrous, lymphoid and fatty. There 
is often a decrease in the osteoblasts. In the radiographic appearance there 
are three groups. Type I, the thick bone type, seen most in severe pre- 
natal cases, have short major long bones, which are usually broad and thick, 
the proximal ends being most affected. Other bones are osteoporotic. 
Type II is the slender, fragile type which occurs in the pre-natal cases 
that survive and in all the post-natal cases. All the bones are osteoporo- 
tic and the long bones are usually slender. The cortex is thin. They may 
be of greater density at the old fracture sites. Transverse lines of dense 
bone, straight or wavy, often mark the ends of the metaphyses. The fibula 
may be just a faint line. The skull is thin. The vertebral bodies are 
shallow, spread, biconcave and rarefied. In Type III we have osteogenesis 
imperfecta cystica but it is rare and in it the cystic changes are more 
pronounced in the lower extremities. It is progressive. 
Conklin and Koloski (29) report a case with typical findings of osteo- 
genesis imperfecta except that the patient was not deaf. Osteogenesis 
imperfecta is a disease characterized by multiple fractures, generalized 
osteoporosis, blue sclera, deafness and relaxed ligaments. According to 
Sante it exists in three forms, (1) congenita, (2) tarda or infantile and 
(3) idiopathic osteopsathyrosis. The first two are congenital and have 
blue sclera but the last does not have the blue sclera. In congenita, the 
fractures occur at birth and these patients usually die in infancy. In 
the tarda form, the fractures begin about the time they begin walking and 
the idiopathic have the fractures start about the age of three years. Blue 
sclera is a typical Mendelian characteristic, and £0$ of children of a 
heterozygotic person and a normal person will have the blue sclera and 
brittle bones. These individuals are usually short and thin. The head 
often shows prominence of temporal, occipital and frontal areas. 
Vandemark and Page (30) report massive hyperplasia of bone following 
fracture in two cases of osteogenesis imperfecta. The condition must be 
differentiated from malignancy, myositis ossificans, ossifying hematoma, 
and osteomyelitis. The reaction due to a quantitatively exaggerated repair on the part of the osteoblast. 
Sickle Cell Anemia 
A case of sickle cell anemia is described by Weil and Lerner (31)• 
It shows unusual roentgen changes in skull, tubular and flat bones. The 
bones of the skull vault were extremely thick; the tables could not be 
delineated because of the increased density of the calvarium. The mastoid 
showed an almost complete lack of pneumatization. There was an irregular 
defect in the left parietal bone measuring 1,5 x 2 cm., with a sclerotic 
margin. The metacarpals and phalanges showed almost complete loss of the 
trabecular pattern of the shafts and marble thickening of the cortex. The 
second phalanx of the right middle finger and the fifth right metacarpal 
bone shored cyst-like areas within the medullary cavity with expansion of 
the shafts. Both fibulae and ulnae showed cortical thickening. Some bones 
showed widening and increased trabeculation of the medullary cavity with 
thinning of the adjacent cortex. There was marked variation in density 
suggesting cyst formation. The upper third of the left tibia showed marked 
overgrowth of cortical bone with encroachment on the medullary cavity. 
Paget*s Disease 
Hamilton (32) presents the findings in the maxilla of a well established 
case of "generalized Paget's Disease, The enlarged maxilla stretched the cv*r- 
lying mucosa so that the vessels were distinctly outlined. Dental roentgeno- 
graphic examination showed moderate to advanced resorption of the alveolar 
process around the remaining teeth. The maxillary bone revealed zones of 
almost confluent trabecular pattern, in a background of almost uniform 
diffuse increase in density. In the upper right molar region, there was 
an area which revealed several nodular appearing sclerotic portions, A 
fragment of bone removed from the maxilla for biopsy showed the usual histo- 
logical findings in this disease. 
Meirowsky (33) calls attention to the significance of vacudles in phy- 
siol ogicaTliinci pathological conditions, and offers additional evidence for 
the resemblance of vacuoles in Paget's disease to various other disorders. 
Using a technique employing Mallory's connective tissue stain, the author 
demonstrated virus-like bodies in the vacuoles of common plantar and genital 
warts, and in four early cases of Paget's Disease found similar virus-like 
bodies in the vacuoles. He could not demonstrate the same bodies in the 
advanced cases of Paget's Disease, BIBLIOGRAPHY 
1. Elgenraark, 0.: Development of ossific centres in some diseases in 
early childhood, Acta Paediat., Suppl. 3£: 207-211*, 19U8 
2. Haas, S. L.: Mechanical retardation of bone growth, J. Bone and Joint 
Surg., 30A: £06-512.Apr, 19^8 
3. Ross, D,s Disturbance of longitudinal growth associated with prolonged 
disability of lower extremity, J. Bone and Joint Surg*, 30A; 103-il5'# 
Jan. 19U8 
i;. Fuller, Robert and Woolf, Douglas L.; Short leg in soldiers, Brit. 
M, J. 2: 109, July 19U9 
£, Sydow, G. Von: Development of rickets in premature infants, Acta 
Pediat, 3£: 169-17,6.Suppl. 1, 19U8 
6. Man, T. J. de and Hoff-Jorgensen, E.: Yeast and rickets, Nature, Lond., 
162: £7U-£7£, Oct. 19U8 
7. Portal, A.: Observations on nature and treatment of rickets, Occup. 
Therapy, 27: Iil£-Jil9, Oct. 19U8 
8. Shuman, H. H.: Infantile cortical hyperostosis, J. Pediat., 32s 19£- 
202, Feb. 19U8 
9* Zeben, V/. Van: Infantile cortical hyperostoses, Acta Paediat., 3£: 
10-20, July, 19U8 
10. Gordon, E. J., Perlman, A. W., and Schechter, N.s Diffuse inflammation 
of cartilage; a case report of hitherto unreported entity, J. Bone 
and Joint Surg., 30A: 9Uii-9£6, Oct. 19U8 
11. Swenson, Seland L.s Osteochondritis dissecans and osteochondromatosis, 
J. Michigan M. Soc., hi: 728-736, July 19U8 
12. Fairbank, H. A. T.: Osteopetrosis, J. Bone and Joint Surg., 30B; 339- 
3£6, May 19U8 
13* Rugg-Gunn, M. A.; Case of ,f marble-bone” disease, J. Roy. Nav. M. Serv., 
33s 312-3l£, Oct. 19U7 
lii. Fairbank, H. A. T.: Osteopoikilosis; osteopathia condensans disseminata, 
J. Bone and Joint Surg., 30B; £I|i*-£i±6, Aug. 19U8 
:3o 15. Fairbank, H. A. T.; Melorheostosis (Leri type of osteoporosis: Osteosi 
eburnizzante raonomelica (Putti) ), J. Bone and Joint Surg. 30B: 533-5U3* 
Aug. 19U8 
16. Fairbank, H. A. T.; Metaphyseal dysostosis, J. Bone and Joint Surg., 
30B: Nov. 19U8 
17. Albright, F.« Osteoporosis, Ann. Int. Med., 27: 861-832, Dec. 19^7 
18. Kesson, C. M., Morris, N., and McCutcheon, A.; Generalized osteoporosis 
in old age, Ann. Rheuraat. Dis., 6: 1U6-161, Sept. 19U7 
19. Lauber, H. C., Weber, F. P., and Greenfield, J. G.s Idiopathic extreme 
osteoporosis, expecially of the spinal column and thoracic cage, with 
collapse of front of chest, Ann. Rheumat. Dis., 7s 127-131* Sept. 19U8 
20. MacMahon, H. Edward: Skeletal changes in Albright's disease, Am. J. 
of Path. 2k: 682-68U, May 19U3 
21. Aegerter, Ernest: Neurofibromatosis and its relationship to certain 
diseases of bone. Am. J. Path., 2U: 68U, May 19^8 
22. Windholz, F. and Foster, S. E.s Sclerosis of bones in Gaucher's dis- 
ease, Am. J. Roentgenol, 60: 2U6—25Q Aug. 19U8 
23. Smyth, Francis S.: Some observations on the so-called Hand-Schuller- 
Christian syndrome. Pediatrics, 1: 396, March 19U8 
2iu Way, C. Berkely; Leontiasis ossium, Lancet, 2: U57* Sept. 191*8 
25« Hughes, E. S. R.; Osgood-Schlatter's disease, Surg. Gyn. and Obst., 
86: 323-328, March 191*8 
26. Kridelbaugh, V/. V/. and Wyman, A. C.: Osgood-Schlatter's disease. Am. 
J. Surg., 75: 553-561, Apr. 191*8 
27. Fairbank, H. A. T. and Baker, S. L.: Hyperplastic callus formation, 
with or without evidence of a fracture, in osteogenesis imperfecta, 
Brit. J. Surg., 36: 1-16, July 19U8 
23. Fairbank, H. A. T.: Osteogenesis imperfecta and osteogenesis imperfecta 
cystica., J. Bone and Joint Surg., 30B: 161*-136, Feb. 191*8 
29. Conklin,S. D. and Koloski, E. L.: Osteogenesis imperfecta, case report, 
Guthrie Clin. Bull., 18; 22-21*, July 191*3 30. Vaidemark, W. E. and Page, M. A.s Massive hyperplasia of bone 
following fractures of osteogenesis imperfecta; report of two cases, 
J. Bone and Joint Surg. 30Aj Oct. 191*8 
31. Weil, I. F. and Lerner, H. H.s Case of long standing sickle cell anemia 
with marked bone changes, Am. J. Roentgenol, 60: 25l-25>5>, Aug. 191*8 
32. Hamilton, P. H.: Manifestation of Paget’s disease in the maxilla, J. 
Oral Surg., 6; 17i*-176, Apr. 191*8 
33* Meirowsky, E.: Vacuoles in Paget’s disease, Exper. Med. and Surg., 6: 
203-212, May-Aug. 191*8 SECTION 3 
TUBERCULOSIS OF BONES AND JOINTS 
Prepared by Harold S. McBurney, Lt. Colonel M.C., USA 
One of the most complete and carefully compiled works on bone and 
joint tuberculosis presented during the year 19U6 was the volume entitled 
"Skeletal Tuberculosis" written by Sanchis-Olmos (1) who is Assistant 
Director of the National Institute of Reeducation of Invalids in Madrid, 
Spain. This volume has been translated by Kuhns of Boston. The volume 
represents a most excellent review of the entire subject and contains a 
full and complete bibliography of the literature thereto pertaining. 
A good brief but thorough thumb-nail sketch and survey of Tuberculosis 
of Bones and Joints was written by Malkin (2) of London. It covers the 
methods of spread and the pathological sites of these conditions as well 
as the diagnosis and treatment. 
The nursing care of the patient with bone and joint tuberculosis 
with its problems and solutions has been presented well in two articles 
in the American Journal of Nursing, (3) (U) 
Although the use of B.C.G. Vaccine has not received much popularity 
in the United States it behooves us to review the history and development 
of its use, McKone (5) of Canada has written a most carefully prepared 
and thorough article entitled "Review of the Literature on B.C.G. Vaccine 
and a Discussion of its Present Day Value in Protection against Tubercul- 
osis," Its conclusions are that B.C.G. must be made in centers specializ- 
ing in its production in order to avoid contamination and danger. If this 
is done the vaccine is innocuous for both animals and humans. Local and 
general reaction following vaccination is negligible. The figures of its 
value in study with controls cannot be denied. It has a definite place 
for employees of sanatoria and hospitals and for children who are tuber- 
culin negative and who have parents in hospitals for tuberculosis, Wall- 
gren (6) of London has offered some principles for the use of B.C.G, Vaccine 
which are worthy of review. They are: 1-The vaccinated person must be 
repeatedly tuberculin tested and protected against exposure to infection 
by tuberculosis until they become tuberculin positive, 2-Nothing is 
gained in B.C.G. Vaccination to tuberculin positive people, 3-In a 
known case of exposure it is advised to wait at least six weeks and then 
vaccinate only if the patient is tuberculin negative. There is no danger 
in vaccination in a positive person but this confuses the picture, U-The 
duration of B.C.G. sensitivity is usually from two to ten years. The longer 
it lasts, means that a subclinical infection with tuberculosis has been ac- 
quired. 5-Tuberculosis in B.C.G, cases means that conferred immunity is 
only relative, 6-There is no reliable way to distinguish tuberculin sensi- 
tivity due to B.C.G. and that due to infection. 7-Immunity holds as long as 
a positive tuberculin test is positive and if a positive test goes to a negative then revaccination with B.C.G. is demanded. 
Studies in the chemotherapy of tuberculosis using mainly laboratory 
methods were done with the sulphones, proraizole and sulphretone. (7) (8) (9) 
Although high therapeutic activity was shown in vitro with these chemicals 
there was little or no clinical evidence of in vivo activity in the human. 
These chemicals as well as an antibiotic called subtilin (10) from the B. 
Subtilis were not used in any case of bone or joint tuberculosis. 
The use of streptomycin both in laboratory and experimental animals 
as well as in the human found a prominent place in the literature for 19U8. 
Corper and Cohn (11) using laboratory animals found that streptomycin does 
net destroy the virulent human tubercle bacilli nor completely retard their 
development in vivo. It does not affect the viability of avirulent human 
tubercle bacilli in vivo. In experimental virulent infection streptomycin 
did retard tuberculosis activity but it could not prevent a lethal outcome 
and in their series no animal escaped. The mechanism of streptomycin action 
in vivo is not known. It has too an unstable in vitro retarding unit value 
in simple mediums for the tubercle bacilli. They suggest much more control- 
led studies of this antibiotic and stress the use of streptomycin as an ad- 
junct and advise the continuation of standard sanitoriurn treatment. Pfuetze 
and Pyle (12) described the uses and limitation of streptomycin in tubercu- 
losis. They state that it is effective in at least fifty per cent of patients 
treated. Used early in the disease streptomycin may result in disappearance 
of symptoms and the X-ray may show evidence of healing. In the chronic case 
the surgical treatment is more successful after adequate chemotherapy especi- 
ally where draining sinuses are present. The limitations listed arej There 
is little effect on far advanced pathological changes; it suppresses tub- 
erculous infection but does not eradicate it; there is a development of 
resistant strains and finally there is the element of toxicity in its use. 
They recommended a dose of one gram a day for five to six weeks. Amberson 
and Stearns (13) stated some general conclusions in relation to the use of 
this drug in pulmonaiy disease chiefly. It promotes control of acute in- 
flammatoiy changes by arrest of bacterial activity. It may help in avoid- 
ing extensive caseous necrosis by putting less demands on the patient’s 
vital resistance thus giving respite for the natural healing process. Re- 
lapse and drug resistance are discussed and the time of administration is 
advised to be long in the desperate case and short in the mild one. Above 
all a plea is made not to abandon rest with the use of this new agent, 
Feldman (lU) states that streptomycin causes a loss of progressive momentum 
in tuberculosis and also causes earlier tissue healing. Its limitations 
are that it has less action in vivo than in vitro and that its use does 
develop drug resistance. The tissues must be rehabilitated by natural re- 
sistance after the acute infection is suppressed. Therefore chemotherapy 
plus medical and surgical help is always needed and streptomycin is viewed 
as a valuable adjunct. 
Specific work was done and reported on drug-resistant tubercle bacilli 
in patients under treatment with streptomycin, Wolinsky, Reginster and 
Steenken (15) presented a series of forty-seven studied patients who were 
under an average dose of one gram a day. In general cultures of tubercle 
bacilli isolated from untreated cases were sensitive to 1,0 mcm cc of 
streptomycin but tubercle bacilli resistant to the action of 10 mcm of 
streptomycin/cc were found commonly in patients under streptomycin treatment. 
The longer the duration of treatment with streptomycin the more drug resis- tant cultures were obtained - for example, thirty-seven per cent of their 
patients developed drug resistance after twelve weeks. Their plan was 
then to give the drug for four to six weeks at which time about seventy- 
five per cent of positive cultures may be expected to be still sensitive. 
They stressed that streptomycin resistance is a relatively long lasting 
characteristic of the tubercle bacilli both in vitro and in vivo. The 
results of treatment with streptomycin in patients harboring drug resis- 
tant organisms have not been encouraging. Bernstein, and Steenken 
(16) reported a series of forty five patients with pulmonary tuberculosis 
treated with one gram of streptomycin for one hundred and twenty days. 
Prior to therapy the tubercle bacilli isolated from the patients were sensi- 
tive to 1.0 mcm of streptomycin per ml of medium. After one hundred and 
twenty days of streptomycin administration, tubercle bacilli were recovered 
from the sputum or gastric washings of thirty-one patients or sixty-nine 
per cent of their series. In twenty-six of these patients the tubercle 
bacilli were resistant to 10 mcm of streptomycin per ml, that is, eighty- 
four per cent of the patients in this group, showed drug resistance. Even 
eighteen strains were found to be capable of growth in over 1,000 mcm* It 
appeared that streptomycin resistant tubercle bacilli had the greatest rate 
of development in the second month of therapy. They concluded that the 
amount of the dose was not as important as the time factor and that there 
must be clinical and laboratory correlation in the use of this antibiotic. 
Other articles have appeared in the literature during this year con- 
cerning the use of streptomycin. These represent in main a review of the 
clinical use of this antibiotic and are referred to in the bibliography 
(17-23) for general reference use. 
Several articles were published describing the use of streptomycin in 
the treatment of bone and joint tuberculosis with and without sinus forma- 
tion. Michele and Krueger (2U) reported twelve cases in which surgery and 
streptomycin were both used. A hip and shoulder case were presented in 
detail in which streptomycin both pre and post-operative combined with joint 
toilet and fusion was used with excellent results. Nalls and Moyer (25) 
report two groups of patients with draining tuberculous sinuses treated 
under a different dosage plan. In the first group of patients twenty-three 
in number, twenty-one were cured under a dosage of 1.8 grams per day in five 
divided doses. The duration of therapy was between three and eight months. 
In the second group of nineteen patients under a dose of 1.0 grams a day in 
two divided doses, eleven were cured and the rest rapidly clearing in thera- 
peutic duration of only one to three months. In the second group there was 
less toxicity noted and less resistant strains developed. They felt that 
the two dose daily method maintained a better blood level. Their general 
plan in the treatment of draining tuberculous sinuses was to give strepto- 
mycin for thirty days after healing or a total of one hundred and twenty 
days whichever is shorter. Brock (26) reported a series of twelve patients 
with a grand total of sixty draining’”sinuses, in ten of these patients the 
sinuses lead directly to bone. 1.8 grams of streptomycin was given daily 
for ninety days to six, and to the remaining six for one hundred and fifty 
days. There was mild toxicity in many of these cases but none of a perman- 
ent nature. All the patients had a sense of well being and there was an 
average gain of fifteen pounds. Fever was abated in all cases. Of the 
sixty sinuses, fifty-nine were closed eight months after starting the strep- 
tomycin therapy. Sinuses closed in from one to twenty weexs. It is stressed 
that the effect of streptomycin is enhanced by adoption of the surgical prin- ciple of free drainage and sequestra removal. Bickel and Young (27) 
present sixteen patients treated with streptomycin, three with multiple 
joints involved and four sinuses present before treatment. One hundred 
and twelve days was the average duration of t reatment and one hundred and 
thirty-four grams was the average total dose. There was toxic reaction 
classified as mild to moderate in nine patients• Of the sixteen treated 
there was a favorable result in nine, fair in one, no benefit in four and 
in two it was too soon in the therapy to make a decision. The sites in- 
volved in this series were: knee, spine, ankle, wrist, shoulder, elbow, 
ilium and sacro-iliac joint. The authors suggest a dose of one gram daily 
for ninety days, Kincade and Saxton (28) reporting the use of strepto- 
mycin in the treatment of one hundred cases of all types of tuberculosis in- 
cluded three cases of tuberculous osteomyelitis. These cases received one 
gram daily for eight weeks in two daily doses. In two the sinuses cleared 
up with one recurrence and in one there was temporary improvement. No bone 
changes were noted by x-rays. 
(Note: Today the trend continues toward a smaller dose of streptomycin 
and an increase in the time interval of administration coupled with such 
drugs as para-amino-salicylic acid. Our present regimen at the Fitzsimons 
Army Hospital is two grams of streptomycin with twelve grams of para-amino- 
salicylic acid every three days for thirty doses. Results are good with 
practically no limitation,) 
The old fixed concept that every case of a tuberculous lesion of the 
spine presented a narrowed disc space with vertebral body destruction cannot 
be held today in its entirety for many proven cases of tuberculous spondy- 
litis do not give this picture. A most instructive pathological and x-ray 
review of multiple tuberculous lesions of the spine is given by Feuchtwanger 
(29). His conclusions are given here as they represent a progressive view- 
point in orthopaedic pathology and diagnosis. He presents a case of multiple 
areas of spondylitis showing combined pathological changes. This case was 
followed for eighteen months with x-ray and finally came to post-mortem 
examination. Tuberculosis of the spine is not always a purely destructive 
process and many times shows bone production or sclerosis and this finding 
therefore does not mean evidence of a secondary infection. The disc space 
in tuberculosis may show two changes; It is often preserved despite exten- 
sive bone destruction of several bodies; early narrowing may be caused by 
extrusion of the nucleus pulposus into the softened bony or ligamentous struc- 
tures, The disc space in pyogenic infection shows early and complete loss 
due to proteolytic enzyme action from the polyraorphoneutrophiles in the 
exudate. Pyogenic spinal infection is usually confined to the neural arches 
and tuberculosis is uncommon here. In the spread of tuberculosis of the 
spine the extension of the abscess is under the anterior longitudinal liga- 
ment and there is surface invasion of the vertebral bodies anteriorly. The 
annulus fibrosis shows little reabsorption even in contact with the abscess, 
in pyogenic spread however, there is direct extension through the disc from 
body to beefy- and this is not found in tuberculosis, Gibbus is uncommon in 
non-tuberculous spondylitis. Spinal cord pressure and slow spastic paraly- 
sis is common In tuberculosis. Meningitis on the other hand is more common 
in the earifyr stages of pyogenic osteomyelitis. It is to be remembered how- 
ever, that the secondai*y infection of a tuberculous psoas abscess may give 
the pathological and x-ray changes of osteomyelitis only. The bone in tub- 
erculosis of the spine assumes two pathological forms; it may be destructive, that is exudative or caseous; or productive, that is sclerotic. Both of 
these forms may be seen in multiple involvement of the spine. Pott's 
disease is the first type with extension into the disc space with body 
weight compression causing gibbus. In the second form the body and disc 
space are maintained. In the healing of both types the bone marrow is 
stimulated to fibrosis and osteogenesis by toxic substances liberated by 
the necrosis of the tubercle bacilli. There is gradual apposition of lay- 
ers of sclerosis in the diseased bone layers. Sclerosis is an aseptic 
necrosis due to loss of blood supply as shown by Bosworth and Cleveland, 
Both caseation and sclerosis may be seen at the same time. By x-ray the 
old concept was bone destruction without sclerosis and minimal new bone 
formation. Today many cases are noted with sclerosis which do not have 
secondary bone infaction. In pyogenic osteomyelitis the rarefaction is 
more definite and circumscribed, A paravertebral abscess may be the first 
sign of disease with no alteration of the vertebral body or disc space in 
the productive type. This has been definitely demonstrated by Bosworth, 
A most complete and thorough article on Tuberculosis of the Spine in 
Children was written in 19U8 by Cave (30) at Massachusetts General Hospital, 
Norcross (31) reports two most interesting cases of compression of the 
spinal cord due to direct extension from a tuberculous pulmonary abscess. 
Only two cases have been previously reported so it is assumed that this 
condition is rare. The first case had a tuberculous cavity at the base of 
the right upper lobe and from this focus a tract extended along the third 
and fourth ribs, destroying portions of these and the third and fourth pedi- 
cles of the thoracic vertebrae. It then entered the intervertebral foramen 
and thence to the spinal canal and enveloped the cord and compressed it. 
In the second case a sinus extended from an apical pulmonary lesion around 
to the back involving the spinous processes of the third, fourth, and fifth 
thoracic vertebrae and thence into the intervertebral foramen, into the canal 
and caused cord compression. These cases reported are therefore not true 
Pott's disease and not the common extension from an abscess about a spondy- 
litis extending through the disc space and posterior ligament to the cord. 
Dalgamo, Puckey and Nelson (32) report a case of empyema followed by 
Pott's disease in which the eleventh thoracic vertebra was compressed but in 
which there was no paralysis. 
Pott (33) presents the treatment of Pott’s paraplegia by skeletal trac- 
tion and anterior decompression in a series of twenty-one patients. Eight- 
een anterior decompressions were done and of these twelve were in the dor- 
sal area. The average duration of symptoms was two years. All cases showed 
a spinal fluid block, in fifteen it was complete and in four partial. Para- 
vertebral abscess was present in all but one case. The cord compressing 
agents were described as follows: displaced disc in eight; bone of internal 
gibbus in four; sequestration in three; debris in two; and fluid abscess in 
one. Traction is advised with surgery. The operation is one of a postero- 
lateral approach, the erector spinae are displaced inward. Removal of ends 
of ribs, transverse processes, pedicles and some portions of the bodies 
follows. The anterior surface of the theca is then exposed, A burr is 
found useful in sclerotic bone cases. The indications for operation are as 
follows; rapidly progressive paraparesis; progressive paraparesis in spite 
of treatment by fixation and postural correction; in the chronic case in 
spite of treatment a slight or moderate paraparesis develops or exists: and 
cases where spasm prevents fixation. There were three deaths in eighteen cases, two from uremia and one from cord injuiy, Results obtained were: 
twelve of fifteen had complete two nearly complete recovery and 
one was too early to state. All cases recovered from the spinal block and 
all showed a good recovery of general health. At the present time all cases 
are placed in traction and are grafted following exploration. In three 
cases sinuses developed and in two of these the sinuses are healing well. 
Somerville and Wishart report a most unusual case of Pott’s dis- 
ease of the spine with rupture of the aorta. An abscess from the 8th dorsal 
extended into the esophagus and thence into the mediastinum and an eroded 
rib protruded into the aorta producing hemorrhage and death. They mention 
one other case of suspected tuberculous spondylitis of the 12th dorsal and 
final aneurysm of the aorta with rupture in the thoracic portion. 
A case of tuberculosis of the greater trochanter is reported by Martin 
(35) in which the x-ray showed no sclerosis of bone and the operation re- 
vealed bone caseation and a millet seed bursa. The author doubts that 
sclerosis means secondary infection. 
A most unusual functional result in a proven case of tuberculosis 
of the hip treated by conservative methods is reported by Upshaw and Bickel 
(36) • The patient was a four year old colored male who was followed Tor 
three and one-half years. Cystic necrosis was present at the epiphysis of 
the neck of the femur. Exploration revealed normal cartilage but biopsy 
tissue was positive for tuberculosis. The patient was casted for fourteen 
months and then wore a caliper brace for ten months more. Final examination 
revealed a healed process and only the slightest limitation of flexion and 
extension, all other motions of the hip joint being normal, (Note: A prov- 
en case of tuberculosis of the knee joint (exploratory biopsy) treated with 
streptomycin and immobilization for eight weeks at the Fitzsimons Amy Hos- 
pital presented a healed lesion and complete normal function and appearance 
at the end of two years.) 
Nissen (37) gives an excellent review of the surgery for arthrodesis of 
the tuberculous hip in England and the present trends toward certain tech- 
niques. He states that no matter how efficient external fixation is, a 
closed tuberculous infection of the hip veiy rarely leads to spontaneous 
fusion and that some form of bone graft is necessary. Five types are re- 
viewed: 1-Hibbs-using a detached trochanter for a bridge across the joint 
line is not used because in adolescence there is too much cartilage at the 
trochanteric site. 2-Ilio-femoral—the time of operation is about the tenth 
year and follows weight-bearing ambulatory treatment. Operation is done 
through a windowed spica using a Smith-Petersen approach. A free full thick- 
ness iliac graft is wedged into slots in the greater trochanter and ilium 
just above the joint line. Correction of joint contracture is done two 
months later by subtrochanteric osteotomy well away from the joint. Good 
fusion is reported in seventy per cent of the cases. Failure in ilio-femoral 
arthrodesis alone is cut down remarkably by use of a high osteotony in combin- 
ation. 3-Brittain-massive tibia! graft driven between fragments of osteot- 
omized femur just below the lower margin of the joint into the ischium and 
beneath it, the upper end of the femoral shaft is displaced inward. Many 
satisfactory results are reported but there is always danger of sciatic nerve 
damage, U-Trumble-a low horizontal graft placed posterior to the sciatic 
nerve between the tuberosity of the ischium and the femur gives good results and avoids sciatic nerve injury* (Note: Van Gorder of Boston has presented 
a modification of this method with excellent final results.) 5-Wilk±nson- 
uses a high displacement osteotomy getting the upper end of the lower femoral 
fragment into contact with the pelvis. The lesser trochanter unites with 
the ischium without use of graft. Many early successful fusions are reported 
and this procedure may be used at an early age before a graft is feasible and 
even in the presence of sinuses. Deformity and strain are removed by inward 
displacement of the whole femoral shaft* 
Dobson (38) of England actually presents an analysis of fifty cases of 
arthrodesis in tuberculosis of the hip joint in which the extra-articular 
ilio-femoral (with attached iliac end) arthrodesis was used. Forty of these 
fifty patients have been followed for a period of two years or more. The 
indications for arthrodesis are stated; Unsound fibrous ankylosis at the 
end of the initial period of conservative treatment; painful fibrous anky- 
losis without deformity, and finally the late development of flexion-adduc- 
tion deformity. The operation is performed when the disease is quiescent 
usually at the twelfth or thirteenth year. Fifty-eight per cent were done 
between the eleventh and twentieth years and twenty-six per cent between the 
twenty-first and thirtieth years. The mortality was two per cent. There 
was solid bony ankylosis in eighty-seven and one-half per cent. Full working 
capacity was present in eighty-sevdn and one-half per cent and two and one- 
half per cent did part time work. These cases were immobilized for six to 
nine months and were allowed weight-bearing in three months. 
Birdsong and L*Engle (39) describe the fifteenth reported case of mul- 
tiple cystic tuberculosis of the bones. The patient was a thirteen month 
old white male with cystic tuberculous lesions in the flat and long bones 
as.well as in the bones of the hands and feet. The osseous lesions were 
secondary to tuberculosis elsewhere and were spread through the blood stream. 
Jorio (UO) reports 3U cases in which bone fistulae or cold abscesses 
have favorably responded to local treatment with antiseptic solutions. He 
describes 3 compounds containing ether, alcohol, phenol, iodine, bichloride 
of mercury and zinc chloride. 
Martin (Ul)introduces his article with the statement that the exis- 
tence of tuberculous rheumatism is doubted by many individuals in the United 
States, Most American authors believe that this condition is merely an oc- 
currence of rheumatoid arthritis in an individual who happens to have an 
associated visceral tuberculosis. The author quotes French and Swiss authors 
who believe that in such cases chronic polyarthritis associated with erythema 
nodosum has developed in tuberculous children. The author feels that if a 
streptococcus may be accused of being an etiological factor, so may other 
bacteria such as the gonococcus, brucella, and the salmonella group. 
The author describes U cases in which findings of tuberculosis are 
well documented by post-mortem examination. There was associated poly- 
arthritis in all patients. The literature favoring the theory that tub- 
erculosis may be a contributing factor in the development of the rheumatoid 
type of polyarthritis is reviewed. BIBLIOGRAPHY 
1, Sanchis-Olmos, Vicente: Skeletal tuberculosis, Williams and Wilkins 
Co,, Baltimore, 191*8 
2, Malkin, S, A. S.s Tuberculosis of bones and joints, Practitioner, 
160: 196-20$, March, 191*8 
3, Anderson, H, C,: Nursing the patient with bone and joint tuberculosis. 
Am, J, Nursing, 1*8: 21$-220, March, 191*8 
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of a systemic infection. Am. J, Nursing, 1*8: 213-21$, Apr. 191*8 
$, McKone, B,i Review of the literature on B.C.G, vaccine and a discus- 
sion of its present day value in protection against tuberculosis. 
Treat, Serv, Bull. (No. 1), 3: 3-U*, Jan, 191*8 
6. Wallgren, A. J.: Principles of B.C.G, vaccination, Lancet,! : 237- 
239, Feb. 11*, 19i*8 
7. Hoggarth, E. and Martin, A. R.: Studies in the chemotherapy of tuber- 
culosis; sulphonamides, Brit, J. Pharmacol, 3: 1$3-1$$, June 191*8 
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Johns Hopkins Hosp,, 82: 1*17-1*20, March 191*8 
9. Brownlee, G., Green, A, F. and Woodbine, M,; Sulphetrone, a chemo- 
therapeutic agent for tuberculosis; Pharmacology and chemotherapy, 
Brit. J, Pharmacol., 3: l$-28, March 191*8 
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Topical application of subtilin to tuberculous lesions in man, J, 
Lab, and Clin. Med., 33; 799-801*, July 191*8 
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mycin in tuberculosis, J. A, M, A,, 137: 3$7-362, May 191*8 
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in tuberculosis, J, Iowa M. Soc., 38: 1*67-1*71, Nov. 19U8 
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tuberculosis, Ann, Int. Med,, 29: 221-228, Aug, 191*8 
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1$. Wolinsky, E,, Reginster, A. and Steenken, W,, Jr,: Drug-resistant Tub- 
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resistant tubercle bacilli; incidence in patients treated with strep- 
tonycin., Am. Rev. Tuberc., 58: 3UR-352, Sept. 19i*8 
17, Alston, J. M.: Streptonycin, mother and child, London, 18; 252-255, 
March 191*8 
18, (Author not given) Evaluation of the use of streptomycin in tuber- 
culosis, Connecticut M, J,, 12; 230-233, March 191*8 
19* Barnwell, J, B,; Use of streptomycin in tuberculosis, J, Michigan 
M. Soc., 1*7: 1221, Nov. 191*8 
20, Walker, H, G,; Streptomycin in the treatment of tuberculosis, J, Am, 
M, Women A., 2; 553-551*, Dec. 19i*7 
21, Aven, C. C. and Cruise, J, S,; Streptomycin and tuberculosis, J, M, 
A. Georgia, 37: 376-379, Oct, 191*8 
22, Jacobs, S., Doemer, A. A., and Miller, A. D.; Use of streptomycin 
in the treatment of tuberculosis, Mil. Surgeon, 103: 335-3i*0, Nov, 
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23, Kidney, J. G, and MacLaughlin, E,; Streptomycin in the treatment of 
pulmonary tuberculosis;(presentation of 11 cases treated with strep- 
tomycin at the Newfoundland Government Sanatorium), J, M, A,, Eire, 
22; 3-8, Jan. 191*8 
21*. Michele, A, A, and Krueger, F, J,; Streptomycin and surgery in the 
treatment of tuberculous joints. New York State J, M,, 1*8; 11*70-11*73, 
July 191*8 
25. Nalls, W, L. and Moyer, R. E,; Streptomycin in the treatment of drain- 
ing tuberculous sinuses, Virginia M. Monthly, 75; 369-392, Aug. 191*8 
26. Brock, B. L,; Streptomycin in the treatment of tuberculous sinuses. 
Am. Rev, Tuberc., 58; 35-37, July 191*8 
27. Bickel, W. H., Young, H. H,, Pfuetze, K, H. and Norley, T.: Strep- 
tomycin in tuberculosis of bone and joint, J. A. M. A,, 137; 682-687, 
June 191*8 
28. Kincade, G. F,, Saxton, G. D., Morse, P. W., and Mathisen, A. K.; 
Streptomycin in the treatment of tuberculosis; (report of its use in 
a series of 100 cases), Canad. M, A. J., 59; 105-112, Aug. 191*8 
29. Feuchtwanger, J, L,; Multiple tuberculous lesions of the spine, Brit, 
J, Radiol., 21; 1*00-4*05, Aug. 191*8 
30. Cave, E. F.; Tuberculosis of the spine in children. A, A. 0. S. In- 
structional Course Lectures, Vol. 5, 191*8 31* Norcross, J. R.j Compression of the spinal cord due to direct ex- 
tension from a tuberculous pulmonary abscess, J. Bone and Joint Surg., 
30A; h92~h95, Apr. 1?U8 
32. Dalgarno, M., Puckey, S., and Nelson, M,» Empyema followed by Pott’s 
disease, M. J, Australia, 1; Ul5, March 19U8 
33* Dott, N. M.j Skeletal traction and anterior decompression in the man- 
agement of Pott’s paraplegia, Edinburgh M, J., 5U: 620-627, Nov-Dec 
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rupture of the aorta, J. Bone and Joint Surg., 30B: 327-332, May 19U8 
35* Martin, 0. G.s Tuberculosis of the great trochanter, Brit. M, J,, 1* 
Ul6, Feb.19U8 
36. Upshaw, J. ,E. and Bickel, W. H.; Tuberculosis of the Hip, Minnesota 
Med., 31: 385-386, Apr. 19U8 
37. Nissen, K. I,: Arthrodesis of the tuberculous hip, Overseas Postgrad. 
M. J., 2: lUU, Jan. 19U8 
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of 50 cases, J. Bone and Joint Surg., 3OB: 95-105, Feb. 19U8 
39. Birdsong, M. and L'Engle, C. S., Jr.: Multiple cystic tuberculosis of 
the bones. Pediatrics, lj 767-770, June 19U8 
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ti, Ortop. Traumat. App. Motore, 15: 1, 7-16, Jan-March 19k8 
Ul. Martin, Eric; Tuberculose et rhuraatisrae. Archives De Rhuraatolgie, 7: 
89-96, 19U7 SECTION k 
INFECTIONS OF BONES AND JOINTS 
Prepared by R, S. Brua, Colonel, USAP*, (MC) 
In reviewing the literature for 19U8, with respect to bone and joint 
infections, one cannot help being impressed by the continuing superior 
results attained in the treatment of acute osteomyelitis through antibiot- 
ic therapy as compared with those before the advent of such therapy. Most 
investigators recommend surgical drainage during the optimum period as an 
adjunct to antibiotic therapy. There is general agreement on the fact that 
such therapy should be started as early as possible and should be given for 
a relatively long period in all cases, During this year, there have been 
no new developments in the treatment of secondary or chronic osteomyelitis, 
reliance still being placed on the eradication of dead and infected bone, 
building up the patient's resistance, and the use of antibiotics locally 
and by general administration. The difference in organism sensitivity to 
the antibiotics probably best explains the inconsistent results obtained 
in various series and individual cases. Through the use of antibiotics, 
surgery tends to assume a minor role in the treatment of acute bone infec- 
tion but becomes bolder and more radical in dealing with the chronic infec- 
tions . 
Allen (l) reports the results in 16 cases of acute osteitis treated 
in the pre-penicillin era which are contrasted with 1? cases treated by 
penicillin. The main differences were that in the latter group the acute 
toxemic stage was of shorter duration, there was less bone destruction and 
aspiration was not so often necessary. 
Trueta (2) finds that there is not complete agreement on the results 
of treatment in osteonyelitis after four years experience with penicillin. 
Although the initial septicemic phase can be pretty well controlled with 
chemotherapy, the effect on the bony focus is not always satisfactory. In 
all but the earliest cases, surgical treatment consisting of linear incis- 
ion of the periosteum, drilling of the bone in the involved area, primary 
suture and immobilization, is advocated. Relatively large doses of penicil- 
lin for three weeks are advised. 
Dennison (3) describes the results in 56 cases of osteitis which were 
treated with penicillin. Thirty of these cases were acute with marked tox- 
emia; in nine cases, the bone lesion was the outstanding feature and toxem- 
ia was slight; and in seventeen cases, chronic pyogenic bone infection was 
present. In sixty-nine cases treated before the advent of sulfa drugs, the 
mortality was 33 1/3$, while in seventy cases treated mainly with sulfath- 
iazole, the mortality was 10$, In his present series, the mortality was 
zero. Sequestrum formation requiring surgical interference occurred in six 
cases. The average hospitalization period was thirty-two days. The author 
states that no time limit can be set for the administration of penicillin 
and that routine marrow puncture appears to be the only certain method of control. He states that the administration of penicillin should continue 
until the marrow puncture is sterile. Methods for handling subacute and 
chronic infections of the bone are described. 
Leveuf (U) does not agree with the usual treatment now being used in 
acute osteomyelitis, He normally drains soft tissue abscesses between 15 
and 20 days and condemns bone operations in the acute stage. Formerly, 
the wound was left open but has been closed since the advent of penicillin. 
This author doubts the value of penicillin treatment until after surgical 
interference. Six hundred cases of acute osteomyelitis have been treated 
and the author believes that the first site of lodgement of staphylococci 
in hematogenous osteomyelitis was not usually the raetaphysis but in the 
midshaft near the entrance of the nutrient artery. 
Tucker and Hpllenberg (5) compare the various methods of treatment 
and contrast the results obtained in osteomyelitis. Thirty-nine cases 
comprise the series. The most satisfactory results and the lowest period 
of hospitalization were obtained in those cases wherein 50,000 units of 
penicillin daily was administered for a period of at least twenty-eight 
days. They believe that early metaphyseal decompression in conjunction 
with a long course of penicillin therapy gives better results than with 
penicillin alone. During surgery, stripping of the periosteum is parti- 
cularly advised against. They believe that the sedimentation rate is a 
good barometer as to the progress of the case in that it remains elevated 
as the case progresses unfavorably and decreases as the case improves. 
The need for early diagnosis and immediate therapy is stressed. 
Self (6) compares the results of treatment before and after the ad- 
vent ofsulfanilamides and penicillin. He reviews and appraises cases of 
acute hematogenous osteomyelitis admitted to Babies Hospital, New York City, 
from 193cTthrough 19U6. During this period there were 138 cases. The au- 
thor describes the dramatic onset and severe symptoms and points out that 
bony changes cannot be demonstrated by x-ray before the seventh to twelfth 
day. Trauma and infection elsewhere in the body were the chief etiologi- 
cal factors. Hemolytic staphylococcus was the offending organism in 8? 
cases. Hemolytic streptococcus was the causative organism in 27 cases. 
The causative organism was undetermined in the remaining cases, The femur, 
tibia and humerus were most commonly affected but involvement of nearly all 
bones of the skeleton was present and 2k cases had more than one bone in- 
volved, Seventy per cent of patients with streptococcus infection were un- 
der three years of age. In the staphylococcus infections 60$ were ovef three 
years of age. There were eleven deaths in the series but only one of the 
cases received chemotherapy. 
Wilkinson (?) points out that with early diagnosis and adequate treat- 
ment with penicillin and sulphadiazine, the mortality is almost zero and 
bony changes are minimal. He discusses the differential diagnosis and prog- 
nosis. Before the sulphonamides and penicillin the mortality in 6?U cases 
was 20.7%• Between January and December, there were seven deaths in 
177 cases, a mortality of 3.9$. A detailed description of the therapy is 
given. Vuori and Sulamaa (8) have collected 83 cases of acute and chronic 
osteomyelitis that were treated by penicillin. Surgical treatment was 
required in some cases. The initiation and rate of penicillin administra- 
tion varied so much that reliable statistics were difficult to obtain; 
however, the authors conclude that early penicillin administration and 
adequate dosage are very important factors. They believe that surgical 
interference is necessary in a certain per cent of cases. 
Trueta and Agerholm (9) discuss effectively and in detail, the care 
and treatment of acute hematogenous osteomyelitis. They stress the need 
for early diagnosis. Treatment is described under four headings: Peni- 
cillin, Surgery, Immobilization and After Care. These authors believe 
that surgical drainage is indicated when pus is present. During the recov- 
ery period, x-ray and sedimentation rate determinations are considered the 
most helpful indicators of stages in the disease process, (Note; Excel- 
lent illustrations accompany this article and it is well worth reading in 
toto. This paper has been republished in another bulletin (10) as shown 
in the bibliography.) 
Metcalfe (11) describes the therapy in several cases of osteomyelitis. 
One case maintained a bacteremia for seven days in spite of heavy dosage 
with antibiotics. The importance of massive, specific antibiotic dosage 
and adequate supportive treatment is emphasized. Attention is called to 
the use of streptomycin in appropriate cases. 
Buchman (12) reports a case of chronic osteomyelitis of many years 
duration in a 28 year old female illustrating the misuse of antibiotics. 
She was treated with several courses of penicillin and improper surgery 
which resulted in the development of severe urticaria and finally necess- 
itated the application of a tent for administration of oxygen. The peni- 
cillin produced no improvement in the bone infection or the draining sinus, 
The author outlines the proper treatment of cases after recovering from the 
reaction to penicillin. Wound cultures were made. Sensitivity of the or- 
ganisms to both penicillin and streptomycin was determined. Streptomycin 
was used intramuscularly and locally in conjunction with proper surgery 
which comsisted of saucerization after excision of skin scar and finally 
plastic closure. Fortunately, the organisms were sensitive to stteptonycin 
but were not toxic to the patient. The result was excellent. 
Beerman (13) reports the treatment of seven consecutive cases of acute 
hematogenous osteomyelitis of the long bones in infants and children. The 
two infants treated in this series manifested rapid resolution of the dis- 
ease under penicillin therapy, which consisted of 20,000 units every three 
hours for nineteen days in one case, and 15,000 units every three hours for 
ten days in the other. The good results, the author feels, are principally 
due to the fact that penicillin therapy alone, or in combination with sulfa- 
diazine, was started early in the course of the disease in all patients, A 
high degree of suspicion for this disease is considered important. Conditions 
that must be differentiated from acute osteomyelitis are acute arthritis, 
cellulitis, scurvy, syphilis, thrombo-phlebitis, poliomyelitis and rheumatic 
fever. If these cannot be differentiated conclusively, it is preferable 
that they be treated unnecessarily with penicillin rather than that possible 
osteomyelitis go untreated. Surgery was used in one of these cases. The 
author believes that the amount of bone destruction and the necessity for surgery are related directly to the number of days delay in instituting 
penicillin therapy, A plan has been developed by the author for the medi- 
cal handling of this disease and is discussed in some detail. 
O’Brien and Mira (lU) describe the results obtained through the use of 
penicillin and/or sulfonamides in 2U cases of acute hematogenous osteonye- 
litis in children. No surgical treatment was employed but multiple aspira- 
tions of soft tissue abscesses were carried out in some cases. They give a 
detailed account of the treatment employed, complications which ensued and 
results obtained. 
Hutter (15) believes that osteomyelitis in infants should not be con- 
si dere3”lTljenign infection and that all minor infections in the newborn 
should be considered as precursors of severe infections and treated accord- 
ingly, In the cases reported, some antecedent infection was present in the 
majority. It requires about one week for typical bone changes to occur that 
can be visualized in the x-ray; however, there is one significant finding 
early in the course of the infection that may lead us to suspect osteonye- 
litis; namely,widening of the joint space. The author describes the results 
in six cases of osteomyelitis in infants under six months of age from 1$U3 
to 19U7 that were treated with penicillin and sulfadiazine. The mortality 
was zero as contrasted to a group of twelve cases between 193U and 19U3 
wherein the mortality rate was 58$. All of these cases were due to staphylo- 
coccus infection. Ninety per cent of the cases reported showed involvment 
of the hip joint. The joint capsule becomes distended by inflammatory exu- 
dates and lateral dislocation of the femoral head from the acetabulum is 
common. This dislocation is the earliest roentgenographic finding and should 
cause one to suspect an inflammatory process in and about the joint. One 
should give a guarded prognosis for complete recovery without deformity, 
especially in the severe type of infection. 
In statistics by the Navy (16) diseases of the motor system rank high 
as a cause of morbidity and disability and osteomyelitis as one of these 
diseases, has consistently shown the highest number of sick days per case. 
During the war years (World War II), the average annual incidence rate for 
osteomyelitis was 35.9 per 100,000 strength, compared to 30,6 for the per- 
iod 1936 through 1939* Comparing the relative number of cases of osteomye- 
litis which were deemed to have existed prior to entry into the Service, it 
was found that for the period 1936 through 1939, an average of only U,8$ of 
the cases existed prior to entjy into the Service, compared to an average 
of 17.6$ for the war years. 
McKelvey (17) discusses the management of both acute hematogenous os- 
teomyelitis and chronic osteomyelitis, stressing the surgical treatment of 
the latter. 
Illingworth (18) in a textbook of Surgical Treatment, describes the 
clinical course and treatment of acute and chronic osteomyelitis in detail. 
There also is a brief description of developmental diseases of bone and bone 
tumors. Another paper by the same author (19) discusses diseases of joints 
in a concise manner. Spinelli (20) presents a case of septicemia in a seven day old infant 
in which multiple abscesses, acute osteomyelitis of the head of the humerus, 
and pyarthrosis of the same shoulder joint developed* This case was suc- 
cessfully treated by aspiration of the joint, penicillin locally and sys- 
temically, along with immobilization of the joint and supportive therapy* 
Tourney and Shipp (21) call attention to the importance of the use of 
penicillin, obliteration of osteomyelitis cavities through the use of small 
bone grafts and muscle transplants, primary closure after removal of the 
infected bone and soft tissue where possible and the use of split grafts 
to temporarily or permanently cover exposed bone* Thirty patients were 
treated in this series. The duration of symptoms varied from six weeks to 
36 years, with an average of 9i years. The technique of management and 
postoperative care in these cases is described in some detail* 
Graham, Coventry and Ghormley (22) describe the results in 68 cases 
of chronic osteomyelitis treated at the Mayo Clinic during 19UU to 19^6, 
All patients underwent surgical treatment with penicillin being given par- 
enterally. In 27 cases, the wounds were packed open and in Ul cases they 
were closed primarily* The rate of healing was 67% in the first group and 
88$ in the second. These authors believe that in selected cases, primary 
closure is safe and curative, and considerably shortens the period of mor- 
bidity and disability. They contend that radical excision of infected bone, 
combined with penicillin therapy, results in a better chance for complete 
eradication of the disease. 
Hays (23) admirably describes all aspects of sclerosing, non-suppura- 
tive osteomyelitis (Garre's), and presents a case from the onset of symp- 
toms until complete healing has taken place. Attention is called to the 
similarity between the early stages of this type of osteomyelitis and Ewing's 
endotheUomyeloma • 
Reynolds and Zaepfel (2U) believe that the management of osteomye- 
litis secondary to infected, compound fractures, should consist of debride- 
ment and saucerization with closure of the wound if this can be done without 
excessive tension; otherwise, by belated closure, using split thickness 
grafts. They recommend that three months elapse before doing any bone 
grafting. The authors discuss the results in h2 cases. Cancellous iliac 
bone is advocated for use in grafts in these cases. Methods for doing such 
grafts are described. 
Delgarno, Puckey and Nelson (25) describe a case of acute osteomyelitis 
of the femur in a two year old child. There were no manifestations of such 
involvement by x-ray for 2k days following the onset of illness. In spite 
of treatment with penicillin and sulfadiazine from the day of admission to 
the hospital, the infection continued to spread and finally involved the 
entire shaft of the femur. Constitutional symptoms were never pronounced. 
One large sequestrum and several smaller ones were removed surgically and 
the child was discharged from the hospital, walking, after thirteen months. 
MacDonald (26) describes conpensatoiy hypertrophy of the fibula in a 
52 year old man in whom most of the tibial shaft had been removed thirty 
years previously because of osteomyelitis. Scott and Preston (2?) describe a case of Brodie's abscess of the tibia 
in a miner, age 62, consisting of two noneoiranunieating abscesses in the dis- 
tal part of the bone. Soft tissue abscesses were aspirated separately and 
50,000 units of sodium penicillin injected into each cavity. This process 
was repeated three times during the next four days. The patient also receiv- 
ed sulfadiazine and sodium penicillin intramuscularly during this period. 
Nine days following the initiation of the above treatment, the cavity was 
excavated surgically and filled with cancellous bone chips. A needle was 
sutured into the depth of the bony cavity and penicillin instilled every 
three hours through it until removal on the seventh postoperative day. The 
patient also received penicillin intramuscularly. The wound healed primar- 
ily. There was almost complete obliteration of the cavity by x-ray three 
and one-half months following the operation. 
Simmons and Wyman (28) describe a puzzling diagnostic problem in a sev- 
en year old girl. Trauma to the left ankle occurred four months prior to 
admission and surgery was performed seven days following admission. Clini- 
cally, the tentative diagnoses were early giant cell tumor, sarcoma and Brod- 
ie's abscess. Staphylococcus albus was found on culture. 
Rosenberg and Vest (29) describe the clinical features of osteitis pubis 
in four cases, two of which followed a retropubic-prostatectonjy and two fol- 
lowing transurethral resection. They state that it is probably a more common 
clinical entity than is generally recognized and that the x-ray findings are 
characteristic but may not be seen early in the disease. The etiology is 
considered to be infection plus urine retention in the retropubic space. It 
is considered a self-limited disease, the treatment being symptomatic and 
supportive• 
Guri (30) states that certain cases of pyogenic osteomyelitis of the 
lumbar spine may show the same symptomatology as acute, suppurative arth- 
ritis of the hip. During the early stages, there is not a single radiologic 
sign which is pathognomonic of pyogenic spondylitis. The article gives ex- 
cellent differential diagnosis of this condition. Treatment is subdivided 
into that for osteonyelitis involving the vertebral body alone, that involv- 
ing the neural arches only and that involving both. The author believes 
that drainage of deeply situated abscesses is unnecessary as they will be 
reabsorbed later. He concludes by saying that the end result of pyogenic 
infection of the vertebral body is the formation of a vertebral synostosis. 
Brunner (31) has classified twenty-two cases of osteomyelitis of the 
skull and face according to cause and clinical course of the disease, and 
believes that the cause does exert an influence on the course of the dis- 
ease, Osteomyelitis caused by acute frontal sinusitis or by surgery upon 
the sinuses is considered to have an unfavorable prognosis. The author be- 
lieves that antibiotics are of no value in primary chronic osteomyelitis. 
Armer (32) describes a case of acute osteomyelitis of the coronoid 
process following extrabtion of a third molar tooth. The infection was 
controlled by incision, drainage and irrigations, but the coronoid process 
became honeycombed and was removed as a sequestrum. Subsequent regenera- tion took place within the periosteal sheath and no atrophy of the tempor- 
al muscle occurred. 
Birch (33) describes a case of acute paratyphoid B infection with 
accompanying pain in the lower back that turned out to be a paratyphoid 
osteomyelitis of the spine. A tentative diagnosis had been made of early 
ankylosing spondylitis and the patient was placed on a plaster bed for three 
months. X-ray examination of the spine showed complete destruction of the 
body of the fifth lumbar vertebra. Further immobilization resulted in a 
stable and symptoraless spine. The author warns that although the patient 
appeared symptom free three years after onset of the above infection, fur- 
ther symptoms and even abscess formation may develop at any time. 
Rozansky, Ehrenfeld and Matoth (3U) report two cases of paratyphoid 
osteonyelitis, one occurring in a one year old infant and the other in an 
adult, thirty-two years after initial infection. Attention is called to 
the fact that the lumbar spine is involved in about 70% of the cases showing 
lesions of the spine. The authors believe that trauma, strain, fatigue, and 
pyrexia may upset the equilibrium between the latent bacilli and the defense 
mechanism of the body in those cases wherein bone lesions appear many years 
after the initial infection. 
Dehlinger (35) describes a case of abdominal aortic aneurysm with an 
adjacent Salmonella osteomyelitis of the spine, with autopsy findings. The 
aortic aneurysm was considered to be arteriosclerotic in origin and it was 
believed that the osteomyelitis of the spine developed secondarily as a re- 
sult of latent infection, A total of 3h grams of streptomycin given over 
a period of fourteen days, had no effect on the Salmonella infection. The 
author calls attention to the fact that Salmonella osteomyelitis of the 
spine is a very uncommon condition. 
Royster, Kirby and Wilbur (36) describe a case of typhoid osteomyelitis 
of the ribs in a 73 year old man who had had a general typhoid infection two 
years previously. A tender swelling appeared over the lower anterior chest 
several months after he had recovered from the initial infection. On aspira- 
tion, E. typhi were seen on culture. X-rays showed no evidence of bone or 
lung involvement. Sections of the involved ribs and a part of the sternum 
were removed on two different occasions but the wound did not heal. On this 
admission there was a draining sinus in the anterior chest wall which showed 
no communication with the lung under lipiodol injection. The Widal test was 
positive for typhoid in dilution of Ij6u0. A total of 36 grams of strepto- 
mycin was given five days prior to operation and continuing for thirteen days 
postoperatively. At operation, the draining sinus and associated scars were 
completely excised along with adjacent ribs and a portion of the sternum. 
En bloc dissection was carried out so that normal tissue surface remained 
everywhere except over a thickened pleura. Wound was packed with iodoform 
gauze and skin edges approximated except where the ends of gauze protruded. 
The wound was completely healed 55 days after surgery. The authors conclude 
that the use of streptonycin in such a case will not replace adequate excis- 
ion, They call attention to the fact that in the typhoid era, surgeons found that only radical surgery was effective in controlling bony lesions. 
Lowbeer (37) describes the pathological findings in three spines where- 
in patients died of subacute brucellosis, melitensis type, and who had devel- 
oped clinical symptoms of spondylitis. Gross specimens showed small and 
large areas of destruction of the discs and contiguous vertebral bodies in 
the lumbodorsal spine. Occasional small osteomyelitis foci were found in 
the anterior or central portions of the vertebrae. Exostoses were frequent. 
The microscopic findings are described in detail. The author states that, 
although one could not tell with absolute certainty, the above lesions were 
actually caused by Brucella, No cultures were taken directly from the affect- 
ed vertebrae but the inference was strong because the lesions occurred in 
cases of active subacute brucellosis with positive blood cultures. 
Gariepy (38) reports an interesting case of destructive osteomyelitis 
of the fourth lumbar vertebral body in a man 56 years of age, which developed 
fifteen days following urinary infection due to transurethral resection of 
the prostate. Pain was the dominant symptom. There was no response to peni- 
cillin, sulfadiazine or plaster immobilization. Surgical drainage of the 
paravertebral abscess gave temporary relief but the infection spread upward 
to the bodies of the first and second lumbar vertebrae. P, aeruginosa, 
which was-highly sensitive to streptomycin, was cultured from the aspirated 
pus. The patient was given 3,000,000 units of streptomycin daily for ten 
days. His recoveiy was uneventful. The diseased area as seen by roentgen 
examination, was fused by intervertebral bridging of bone with sclerosis of 
the discs. 
Lamphier (39) presents a case of localized coccidioidal infection of 
the os calcis in a 39 year old soldier that did not respond to general and 
local treatment, A below-knee amputation of the extremity was performed and 
was followed by satisfactory wound healing without further dissemination. 
The author believes that the removal of well advanced bone or joint infec- 
tion peripherally should always be considered in such infection because of 
the great possibility that multiple foci will develop. 
Davis (Uo) describes a case of coccidionycosis in which the diagnosis 
was established postmortem. 
Armer (Ul) describes a case of acute osteomyelitis of the mandible 
following extraction of a third molar tooth but apparently not caused by the 
extractions. Subsequent history revealed placement of an amalgam filling 
two days previous to the extractions in the tooth around which the infec- 
tious bone process had started. 
Berman and Sugar (U2) have described a case of osteitis pubis following 
prostatectomy. Etiological factors are discussed. X-ray changes in the 
symphysis do not appear until the third or fourth week. Ankylosis of the 
symphysis generally occurs in the healing process. 
Wilson (1*3) presents 25 cases of chronic osteomyelitis in which the 
discharging sinuses had been present for an average of nineteen months. 
50 Other previous types of treatment had been unsuccessful. The following 
principles formed the basis of the author's treatment: (a) Investigation 
of wound bacteriaj (b) Radical sequestrectomy after adequate preoperative 
preparation; (c) Use of streptomycin and penicillin before, during and after 
surgery; (d) Meticulous wound care after surgery to prevent contamination. 
Sensitivity tests were made on gram positive organisms and the schedule 
of antibiotic treatment is described in detail, Sequestrectony is considered 
the most important single part of treatment. The average time for wound 
healing was about eighty days. The author states that the use of streptomy- 
cin offers no panacea for treatment of chronic osteomyelitis but when com- 
bined with thorough sequestrectomy, is beneficial in promotion of the heal- 
ing process, (Note: This is a well written article that should be read in 
toto.) 
Varadarajan {hh) describes bone lesions in twelve patients out of 1,000 
cases of syphilis as treated in a Burmese hospital. The tibia was the most 
frequently involved bone (four cases), showing an osteoperiostitis of the 
shaft in three cases and an acute osteitis in the fourth, A constant find- 
ing in all cases was an increased sedimentation rate and this is considered 
as the most important guide by the author in assessing activity of the local 
process• 
Esguerra-Gomez and Acosta (U5) confirm an older observation that bone 
lesions of leprous origin are located exclusively in the hands and feet, A 
total of U83 lepers were examined in this study. It was found that in neural 
leprosy as well as in the lepromatous and mixed cases, there is frequently a 
more differentiated trabecular structure in the epiphyses of the phalanges, 
metacarpals and metatarsals than in healthy individuals. The cortex of the 
diaphysis is thinner and the medullary canal is wider than normal. Vacuol- 
ization follows the above changes. Along with adjacent areas of rarefaction 
and hypercalcification, there is occasionally a noticeable widening of the 
proximal ends of one or more phalanges which covers the adjoining phalanx 
like a cap (hooded). This is considered typical of the disease. Leprous 
reabsorption takes two forms: simple reabsorption and reabsorption following 
atrophy. Mutilations are generally symmetrical. In the hands, the reabsorp- 
tion stops at the carpus, while in the foot it usually stops at Lisfranc’s 
articulation. Leprous Whitlow is a true osteomyelitis and presents the same 
appearance as ordinary osteomyelitis radiographically. Fractures are fre- 
quent in leprosy and heal by callus formation, as demonstrated by three of 
these patients. Perforating plantar ulcers may cause infectious arthritis. 
Hypertrophic arthritis is also common due to reabsorption and atrophy. In U6 
healthy children of lepers and twelve without disease, there appeared to be 
no difference in the time of appearance of epiphyseal ossification centers. 
Breckj Basora, Hart and Herz (U6) report three cases of inflammatory 
bone lesions of unusual symptoms and x-ray appearance. They point out that 
chemotherapy has altered the symptoms and radiological study. The reported 
cases had many of the characteristics of malignant bone tumors. Osteogenic 
sarcoma and Ewing's tumor were considered in two of the cases. The authors 
emphasize the importance of a careful biopsy before instituting radical 
treatment. Beilis (U7) calls attention to the importance of tissue tension in 
edema of the extremities, stating that it may rise to ten to twenty times 
that of normal. Immobilization and elevation reduce the tissue tension of 
an inflamed extremity and are of distinct value in supporting the natural 
defense mechanism of the body in extremity infections. The use of such 
treatment appears to rest on a rational physiologic basis. It appears 
that the application of heat under these circumstances is harmful. Immob- 
ilization by plaster cast is considered more efficient than that obtained 
by any other method. BIBLIOGRAPHY 
1. Allen, A. L,: Preliminary report on 39 cases of acute osteitis treated 
without operation. South African M, J,, 22j 103-106, Feb, 1)*, I9I48 
2. Trueta, J.: Treatment of acute osteomyelitis. Lancet, 2s 68, July 10, 
19U8 
3# Dennison, V/« M,s Haematogenous osteitis in children; preliminary report 
on treatment with penicillin, J, Bone and Joint Surg,, 30B: 110-123, 
Feb, 19U8 
I4, Leveuf, J.s Treatment of osteomyelitis; anatomical and physiological 
basis, J, Bone and Joint Surg,, 30B: 207, Feb, 19U8 
5, Tucker, F, R, and Hollenberg, C.s Acute haematogenous osteonyelitis, 
method of treatment. Lancet, Is 701-703, May 8, 19U8 
6, Self, E, B,s Acute hematogenous osteomyelitis, Pediatrics, Is 617-626, 
May 19U8 
7, Wilkinson, F, R,s Diagnosis and early treatment of acute hematogenous 
osteomyelitis in children, J, Pediatrics, 1; 796-798, June 19)48 
8, Vuori, E. E, and Sulamaa, M,s On penicillin treatment of acute hemato- 
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9, Trueta, J,, and Agerholm, M,s Acute haematogenous osteonyelitis; diag- 
nosis and treatment. Postgrad, M, J,, 2s 229-2)40, May 19U8 
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11, Metcalfe, J, W,s Specific therapy in osteonyelitis, U, S, 
ii8s 175-179, March-April 19U8 
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tis, Bull, Hosp, Joint Dis,, 9 s 32-38, Apr, 19U8 
13* Beerman, C. A,s Treatment of acute hematogenous osteonyelitis of the 
long bones in infants and children, J, Pediat,, 33s 578-590, Nov, 19U8 
Du 0!Brien, R, M, and Mira, J. J,s Acute hematogenous osteomyelitis, an 
end result study of nonsurgical treatment with penicillin and sulfo- 
namides, J, Missouri M. A,, 1*5: 75U-756, Oct. 19U8 
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M. 
16. Statistics, Osteomyelitis, U. S, Navy/Bull. U: 6-10, July 19U8 
17. McKelvey, G. J,; Modern surgical methods in the management of osteo- 
myelitis, Rocky Mountain M. J., 1*5: 21-25, Jan 19U8 
18. Illingsworth, C. F, W.: Diseases of bones and joints by J. Bruce, pp. 
176-190, Edinburgh, 3rd ed, 19U7 
19. Ibid; pp. 191-202 
20. Spinelli, V. A.; Septicemia complicated by osteomyelitis in the new- 
born, report of case, Arch. Pediat. 65s 3U7-353, July 19U8 
21. Tourney, J, W. and Shipp, F. L,; Chronic osteomyelitis, S. Clin, North 
Am., 28; 821-829, June 19U8 
22. Graham, F. M,, Coventry, M. B., and Ghormley, R, K.; Penicillin in 
treatment of chronic osteomyelitis, Proc. Staff Meet. Mayo Clin,, 22; 
589-597, Dec. 19U7 
23. Hays, A. T,; Sclerosing, non-suppurative osteomyelitis. Lancet, 68: 
317-323, Aug. 19U8 
2lu Reynolds, F. C. and Zaepfel, F.; Management of chronic osteomyelitis 
secondary to compound fracture, J. Bone and Joint Surg., 30A: 331-33^ 
Apr. 19U8 
25. Delgamo, M., Puckey, S., and Nelson, M,; Osteomyelitis of the femur, 
M. J. Australia, 1; Ul5, March 27, 19U8 
26. MacDonald, A,; Compensatory hypertrophy of fibula in osteomyelitis. 
New Zealand M, J,, U6; 532, Dec. 19^7 
27. Scott, S., and Preston, F. S,; Brodie!s Abscess of the tibia; its 
treatment by surgery, penicillin and sulfadiazine, Brit. M. J„l; 
296-297, Feb. lU, 19U8 
28. Simmons, C. C., and Wyman, S. M.: Brodie*s abscess of tibia. New England 
J. Med., 239: Wi3, Sept. 9, 19U8 
29. Rosenberg, M, L., and Vest, S, A.; Osteitis pubis, J, Urol., 60: 767- 
775, Nov. 19U8 
30. Guri, J. P.; Differential diagnosis and treatment of pyogenic osteo- 
myelitis of vertebral column, M. Press, 218; 569-572, Dec. 19U7 31* Brunner, H.: Osteomyelitis of face and skull, Illinois M. J-, 93: 213- 
220, Apr. 191*8 
32. Armer, A. L.: Osteomyelitis with destruction of the coronoid process 
and subsequent regeneration, J. Oral Surg., 6: 83, Jan. 191*8 
33* Birch, G. A.: Paratyphoid osteomyelitis, Brit. M. J., 2: 398, Aug. 21, 
191*8 
3l*. Rozansky, R., Ehrenfeld, E. N., and Matoth, Y.: Paratyphoid osteomyeli- 
tis; report of 2 cases, Brit. M. J., 2: 297-298, Aug. 7, 19U8 
r. 
35* Dehlinger, K. R.; Salmonella osteomyelitis of spine associated with 
abdominal aortic aneurysm; report of a case, New England J. Med., 238: 
728-732, May 20, 191*8 
36. Royster, H. P., Kirby, C. K.,'and Wilbur, R. C.: Typhoid osteomyelitis 
of ribs treated with streptomycin and surgical excision; a case report, 
Surg. 23: 21*8-2$!, Feb. 191*8 
37* Lowbeer, L.: Brucellotic osteomyelitis of spinal column in man. Am. 
J. Path. 21*: 723, May 191*8 
38. Gariepy, R.: Spondylitis due to pseudomonas pyocaneus treated by 
streptomycin, J. Bone and Joint Surg., 30B; 220, Feb. 191*8 
land 
39• Lamphier, T. A.: Localized coccidioidal osteomyelitis, N. Eng/ J. Med., 
238: 1$0-1$2, Jan. 29, 191*8 
1*0. Davis, C. N.: Coccidioidomycosis; report of a fatal case, Arch. Neurol, 
and Psychiat., $8: 637-639, Nov. 19l*7 
1*1. Armer, A. L.: Osteomyelitis; a case of confusing etiology, J. Oral 
Surg. 6: 177, Apr. 191*8 
1*2. Berman, L. S., and Sugar, S. J.: Osteitis pubis following prostatectomy, 
Bull. Georgetown Univ. M. Center, 1: 232-236, Apr.-May 191*8 
1*3# Wilson, J. C., Jr.: Streptomycin in treatment of chronic infections 
of bone, J. Bone and Joint Surg., 30A; 931-91*1*, Oct. 191*8 
1*1*# Varadarajan, M. G.: Bony lesions in acquired syphilis. Antiseptic, i*$: 
1*67-i*7i*, July 191*8 
!*$• Esguerra-Gomez, G., and Acosta, E.: Bone and joint lesions in leprosy; 
a radiologic study. Radiology, $0: 619-631, May 191*8 
land k6, Breck, L. W., Basom, W. G., Hart, M* S., and Herz, J# R*j Chronic in- 
flammatory lesions of bone resembling neoplasms; report of three cases, 
Texas State J. Med* UU; 386-389, Sept* 19^8 
U7• Beilis, C. J.: Infections of extremities, J. Internet. Coll. Surgeons, 
11; 363-377, July-Aug* 19U8 SECTION $ 
ARTHRITIS AND ALLIED CONDITIONS 
Prepared by 
JOSEPH W. BATCH 
Lieutenant Colonel, M.C., USA 
Assisted by 
VJTLLIAM L. MOFFATT, M. D. 
Memphis, Tennesse 
and 
RALPH M. PATTERSON 
Colonel, M.C., USA 
A review of the literature on arthritis reveals no lack of interest 
or poverty of writings on this subject. Arthritis is increasingly being 
recognized as a major economic and social problem whose etiology, patho- 
genesis and treatment remain unsolved. These factors undoubtedly contribute 
to the failure to obtain a simple universally acceptable classification. 
There is much discussion of chryostherapy, physical therapy and indications 
for surgical procedures in the management of arthritis. 
HISTORICAL AND GENERAL CONSIDERATIONS 
Arthritis is the oldest disease found to occur in man as well as in 
other forms of vertebrate life according to Bach (1). In his interesting 
historical and chronological account of arthritis he relates that as climatic 
conditions changed to become cold and wet, during the Reptile, Mosasaur and 
Dinosaur ages to the time of man, arthritis became more distinctly evident. 
Fossilized skeletons of monsters who lived 110,000,000 years ago have shown 
evidence of arthritis. The ancient Egyptians in their hieroglyphic writings 
tell of man suffering from arthritis, and as early as l£5>0 D. C. deformities 
were described and treatment prescribed by them. Removal of foci of infec- 
tion was recommended by the Egyptians as early as 668-628 B. C. Hippocrates, 
Ii60-370 B. C., is credited with writing the first definite clinical picture 
of arthritis and an attempt at classification. In Ballonius first 
applied the term rheumatism specifically to articular disturbances and made 
a clinical differentiation between acute inflammatory rheumatism and gout. 
This differentiation was elaborated upon by Sydenham. During the l£th Cen- 
tury Villobolos referred to joint complications in syphilis. In 1$93 Petrus 
Forest of Alkaraaar wrote of a case of swollen knee associated with gonorrhea. 
In 168? Wallaston reported the discovery of uric acid in gouty tophi. 
William Cullen, 1777, divided rheumatism into acute and chronic. Richard 
Pott, 1779> described tuberculosis of the spine. David Pitcairn, 1?B8, 
recognized the cardiac complications of rheumatic fever. Edward Sandifort, 
of Layden, 1793, illustrated gross changes in osteoarthritis of the hip. 
In 1800 Landre Beauvais first described the clinical picture of rheumatoid 
arthritis under the title of asthenic gout. Heberden in 1802 described 
nodes found on the terminal joints, which have since taken his name. In 
1810 William C, Wells clearly described "Rheumatism of the Heart.” In I8ij8 Sir Alfred Garrod discovered the high uric acid content of blood in gout. 
In 188U Petrone grew gonococci from exudates of gonorrheal joints, and in 
1888 Weichselbaum recovered pneumococci from joints. In 1897 Goldthwait, 
Painter and Osgood differentiated between atrophic and hypertrophic arthri- 
tis by the use of x-ray findings. In 190? Sir Alfred Garrod*s son. Sir 
Archibald, made a clear distinction between rheumatiod arthritis and osteo- 
arthritis. In 190? Nichols and Richardson described the pathology in chronic 
deforming arthritis. In the same year Pemberton pointed out that obesity 
is a factor in many cases of osteoarthritis. In 1910 Billings crusaded for 
the removal of foci of infection. Miller and Lust, in 1915, advocated the 
use of non-specific vaccines in the treatment of arthritis. In 1916 Chase 
and Fine wrote on the use of cincophen and aspirin. In 1928 Forestier in- 
vestigated the use of gold therapy in chronic rheumatoid arthritis. 
A classical review of the American and English literature of recent 
years, the ninth such review prepared by the Editorial Committee of the 
American Rheumatism Association, has been edited by Bench, et al (2) (3). 
Since the eighth review was prepared concerning this Titerature for the 
year 19U0, a great amount of work has progressed on the subject of arthri- 
tis, even in spite of the vrar years. This new literature has been classi- 
fied, collated and presented in a clear, logical arrangement. The economic 
and social importance of rheumatism in the United States, the British Isles 
and Sweden and the classification of arthritis with a plea for the adoption 
of one classification for use throughout the United States were discussed; 
also, in order, the gamut of arthritic conditions were individually treated, 
covering the incidence, clinical data, roentgenographic and laboratory find- 
ings, etiology, pathogenesis, prognosis and treatment. 
Another review of the arthritides was prepared by Horwitz (I4.), which 
covers the important progress made in their diagnosis during the past few 
years• 
In dealing with rheumatism, Douthwaite (5) considers there are three 
major problems; the first problem is to define, or rather to delimit the 
term; the second problem is to explain the origin of those diseases which 
we call rheumatic, and, the third problem is that of the treatment of 
rheumatism. He states that since the first two problems are unsolved, it 
is not surprising that the third is in an unsatisfactory state. Commenting 
on the third oroblem, he refers to the uselessness of many forms of therapy 
and cites chrysotherapy as being the only major advance made in the treat- 
ment of arthritis for a century. The realization that every arthritic joint 
is an orthopaedic problem from the beginning and the appreciation of the 
value and limitations of spa treatment and physiotherapy are also encourag- 
ing advances of the last thirty years. 
The fact that rheumatic diseases is our biggest medico-economic problem 
is emphasized by Kelly (6), who points out that of the chronic diseases it 
ranks first in theT number of cases, second in the production of costly de- 
formities and fourteenth as a cause of death. He estimates that one out 
of every twenty individuals in this country is afflicted by arthritis, which 
makes it imperative that all physicians have an adequate knowledge of these 
conditions so as to make an accurate diagnosis and employ rational treatment. 
Indications of the high incidence of arthritis in the United States is 
reflected in the markedly increased rate, which occurred in the Navy during the war years* In a statistical analysis prepared by the Navy (7) (8), the 
highest incidence occi ~red in the age group to U9 The average 
annual incidence rate during the period per 100,000 for males was about two 
and one-half times greater than females* All races showed an increase, which 
more or less paralleled, although the rate was higher in the white race. 
(Ed* Note-This statistical study would be more enlightening if it included 
a statistical account of the diagnoses of the disease entities included in 
the report*) 
Ishmael (9) reviewed the arthritides particularly as they occur in the 
aged. TEectegenerative types occur most frequently* Rheumatoid arthritis, 
gout,rheumatic fever, osteochondritis dissecans, the shoulder-hand syndrome, 
malum coxae senilis and bone atrophy with its multiple causes are discussed. 
The incidence of arthritis is shown to increase with age and be higher 
in an industrial population than a non-industrial group by Ferguson (10), 
who quotes from Scotch statistical records. He urges for an expansion of 
treatment facilities in industrial centers where they can be available to 
the majority. 
The establishment of an arthritic clinic consisting basically of four 
specialists, a physician, a surgeon* a medical officer in charge of physical 
medicine and a clinical biochemist, is described by Nicol, Vteugh, et al (11). 
As needs arise, a radiologist, an ear, nose and throat surgeon,a denial 
surgeon, a psychiatrist and a venereologist are added. There is team work 
consultation on each patient, who passes to the care of a particular special- 
ist according to the indications for treatment, after which the patient is 
returned to the clinic for review. 
In order to provide trained personnel to care for arthritic patients, 
the establishment of a Department of Rheumatology in teaching hospitals where 
rheumatologists can be trained has been advocated by Savage (12), Buckley, 
Mason and Nicholson (13), Ellman and Dunn (ll*), and He aid (~15>) ♦ 
Many classifications, soire based on clinical manifestations, others on 
pathologic, roentgenographic or etiologic characteristics have been proposed 
in the past, but none have been universally accepted. Bach (16) relates that 
since the ideal treatment of arthritis is based on its cause, a classifica- 
tion based on etiology is particularly desirable. He presents a classifica- 
tion of the arthritides, which is a modification of that adopted by the Sub- 
committee on Arthritis of the New York City Welfare Council's Committee on 
Chronic Illnesses and that of the Committee on Glassification of the American 
Rheumatism Association. A classification based on whether the pathology is 
(1) chiefly articular, or, (2) chiefly non-articular is suggested by Heald 
(17), who accordingly describes a number of guides for diagnosis and some 
essential keystones of treatment. 
VARIOUS TYPES OF ARTHRITIS 
In a discussion of infectious arthritis Krida (18) reviews the manner 
in which a joint may become infected - from external trauma, extension from 
an adjacent osteomyelitis, and hematogenous from a distant focus. The in- 
fection consequently may involve primarily the synovial membrane, as is most 
common, or by extension from an adjacent bone focus. The symptoms of pain, 
fever, swelling tenderness and limitation of motion develop in the first 2k to US hours. Its subsequent course is dependent upon the virulence of the 
organism and the resistance of the patient. Treatment is directed toward 
rest of the Joint, aspiration or adequate drainage, identification and con- 
trol of the infective agent, general supportive measures, local physiothera- 
peutic measures, and the prevention of deformities. 
Bach (19) reviews the specific forms of infectious arthritis and reminds 
us that arthritis in brucellosis infections may be due to the (1) caprine, 
(2) the porcine, or (3) the bovine type, which are listed in the order of 
their virulence. The average course of fever is six to eight weeks, although 
it may last for twelve weeks. Bed rest, sulfonamides, brucellin and typhoid 
bacteria are proposed for treatment. He states that arthritis is reported to 
occur in 1.7 per cent of cases of scarlet fever and is more common in older 
children developing between the fourth and tenth day. It involves the smaller 
Joints, lasting frorj two to five days. There is no specific treatment. He 
reminds us that arthritis may occur in about 5 per cent of children with con- 
genital syphilis, either during the first month of life or between the ages 
of seven and fifteen years. He states that arthritis occurring during the 
secondary stage of syphilis is very rare while that occurring in the tertiary 
stage is more common due to gummatous formations. A Charcot Joint may develop 
in tabes and usually only one Joint is involved. Joint involvement may occur 
two to five days secondary to an infection with lymphogranuloma venereum 
which responds to sulfanilamide therapy. 
Gonorrheal arthritis is reported to occur in about 3 per cent of patients 
developing gonorrhea and contrary to general belief initially is polyarticular 
in 75 per cent of cases, although following the acute attack it may subside 
and remain localized in one Joint. However, it is pointed out by Bunim (20) 
that with the advent of chemotherapy gonorrheal arthritis is on the decline 
and its severity decreased. He agrees with Bach that at first it may be 
polyarticular, then monarticular with tenosynovitis» He states that it must 
be differentiated from (1) rheumatic fever in which the synovial fluid remains 
sterile and responds to salicylates, (2) rheumatoid arthritis, which does 
not respond to chemotherapy, and (3) Reiter’s syndrome, which begins with 
a non-specific urethritis and arthritis, is self-limited, lasting from four 
to six weeks, leaving the Joints undamaged. Pneumococcal arthritis is a rare 
condition, occurring about once in every 1,000 cases of pneumonia. According 
to Bunim the infections caused by the gonococci and the pneumococci have some 
things in common, in that they both originate from a remote focus and travel 
by way of the lymph and blood vessels to reach the synovial membrane and in- 
vade the Joints, and both organisms are sensitive to chemotherapeutic agents* 
This last consideration has made arthrotomy unnecessary. 
Bach also describes a type of polyarthritis associated with fever, a 
morbilliform rash due to the organism Haverhillia multiformis, which may be 
recovered from the blood or synovial fluid. The attack of red swollen Joints 
may last for several weeks and the cases usually respond to neoarsphenamine. 
In his discussion on tuberculous arthritis Balensweig (21) states that 
any chronic monarticular involvement at any age period should be suspected 
as being tuberculous, although it is more frequent in children and is a 
local manifestation of a general disease. He reports Nathanson and Kahn’s 
study, which revealed that hZ per cent of children and 55 per cent of adults 
are suffering from some form of pulmonary tuberculosis, and Colombani and 
Webster in another study report 50 per cent of the cases show urinary in- 
volvement. It frequently involves more than one Joint as demonstrated in 25 per cent of the adults and 35 per cent of the children in a cited review 
of 200 cases of bone and joint tuberculosis by Nathanson and Kahn, He 
describes the early stages of tuberculous joint disease beginning near the 
end of the long bone close to the epiphyseal line. The bone tissue is slowly 
destroyed, but there is very little skeletal reaction as occurs with other 
bone infections. It finally breaks through into the joint and spreads rapidly 
into the soft tissues. The clinical manifestation, consisting of pain, stiff- 
ness, weakness, atrophy and deformity, are described in general, and then 
he individually reviewed the pathology, clinical course, differential diagno- 
sis, treatment and prognosis of tuberculosis of the spine, hip, knee, sacro- 
iliac joint, elbow, shoulder, wrist and ankle. 
A case of bilateral purulent sternoclavicular arthritis, due to Proteus 
vulgaris, secondary to an umbilical infection, in a new-born girl was reported 
by Bogdanovitch (22). The case was successfully treated with sulfadiazine 
and penicillin. 
Steinberg (23) discusses Brucella abortus infections and reports a case 
of sacro-iliac arthritis due to brucellosis in a 30-year old veterinarian. 
He studied a possible correlation between brucellosis and rheumatoid spondy- 
litis in twenty cases and concluded that none existed. 
Reiter's syndrome, a name apolied to the symptom complex of a non-specific 
urethritis, arthritis and conjunctivitis is discussed by Yviggers (2I4) and 
Jones and Seid (25). Each presented two cases of the condition, which was 
first described in Germany by Reiter in 1916, who thought it was due to 
Spirochaeta forans. This has not been confirmed and the etiology remains 
unknown, Beiglbock believed it to be an allergic manifestation; others 
believe it to be of infectious origin. Staphylococcus, enterococcus, filter- 
able virus and pleuropneumonia-like organisms have been suspected as the 
causative agent. The portal of entry is unknown. Jones and Seid state that 
the symptoms usually begin with a diarrhea followed by urethritis, conjunc- 
tivitis and arthritis and that the symptoms usually subside in the same order. 
About 25 per cent of cases have recurrences. The prognosis is good and no 
fatalities have been reported. According to Wiggers the conjunctivitis is 
present in less than half of the cases. In about 10 per cent of the cases 
a keratosis develops. Balanitis also occurs. Microscopic study of the 
synovial membrane revealed an intense inflammatory reaction of the superfi- 
cial layers only with villi in which a great many.capillaries are greatly 
dilated and marked lymphocytic infiltration. 
Two additional cases are reported by Willcox (26) in 1|1 and hi year old 
males, each of whom had a previous urethritis, one gonococcal and the other 
unconfirmed twelve years before. In spite of treatment with penicillin and 
sulfadiazine the triad of symptoms developed with well marked keratosis on 
the penis. One case was treated subsequently with oral potassium citrate 
and the other with three intramuscular injections of 5 cc of his own blood. 
Both cases ultimately recovered without specific drugs or fever therapy on 
a more or less ambulatory basis. 
A case of polyarthritis with raised, scaly, erythematous lesions around 
the pubis and groin, smaller scattered lesions on the arms and trunk, and 
ulcerated and crusted areas on the toes with thin, brittle nails, was re- 
ported by Wigley (27) in a hZ year old male. There was no urethral discharge. although he had suffered from gonorrhea, followed corneal ulcers and transient 
polyarthritis eleven years previously. Several discussers of the case vary- 
ingly regarded it as a case of rheumatoid arthritis, Reiter's syndrome and 
psoriatic arthritis. 
An additional case is reported each by Quintin and White (28), Masters 
(29) and Florman and Goldstein (30)* The former is a Ul year old male who 
failed to respond to penicillin therapy. Master's case was in a 30 year old 
male who he states responded favorably to mapharsen in conjunction with 
salicylates and physiotherapy, Florman and Goldstein's case was in a k year 
old boy who, following a short period of diarrhea, developed urethritis, con- 
junctivitis and arthritis. Attempts to recover a pathogenic organism were 
unsuccessful, A very interesting observation was high titre of S, Flexner 
VII agglutinins, which fell from a level of 1:1, 280 shortly after onset to 
IsUO several weeks later# 
Lahiri (31) states that most non-specific urethritis proves to be Reiter'! 
disease, which is a syndrome consisting of non-specific urethritis, conjuncti- 
vitis and cutaneous lesions# (Ed. Note - Arthritis is usually considered a 
part of the triad whereas cutaneous lesions appear in only 10 per cent of 
cases.) He mentions a case of subclinical pellagra with a non-specific 
urethritis and conjunctivitis, which failed to respond to penicillin and which 
completely recovered in about two to three weeks on Vitamin B-complex ther- 
apy. He postulates the possibility of a Vitamin B-complex deficiency as an 
etiological factor of Reiter's syndrome. 
In a review of the literature on acute rheumatism during the years 1939- 
19U5 Perry (32) notes a decline in the death rate in the British Isles from 
this disease which roughly parallels the fall in the death rate of strepto- 
coccal infections. A similar trend is reported in the United States. The 
widespread practice of tonsillectomy may have had some influence according 
to Hedley. The age incidence is reported to be between five and ten years 
and rarely after twenty years for the first attack. Females are slightly 
more affected than males. A seasonal incidence is noted, which is highest 
in April and November. A strong familial incidence is noted, and he refers 
to a family reported by Pickles, (19ii3) in which of 53 descendants of a man 
with rheumatic heart disease, 23 had rheumatic fever or rheumatic heart 
disease. He remarks that both heredity and environmental factors may be in- 
volved. Income and density of the population is also reported to have a 
definite influence on the incidence and mortality rates. The interest in 
a virus cause of acute rheumatic fever has declined. The antistreptolysin 
titre is reported to be higher in children with, or who have had, rheumatic 
fever than in normal children. He refers to the work of Clawson (19U0) who 
studied 796 post mortem cases of rheumatic heart disease and who pathologic- 
ally distinguishes four types or phases of the disease: (1) acute rheumatic 
endocarditis (2) recurrent rheumatic endocarditis (3) valvular deformities, 
and (U) adherent pericardium. Three quarters of the cases fall into the 
third group. The work of Baggenstoss and Rosenberg, Fingerman and Andrus, 
Bayles, Bennett, Young and Schwedel, Hall and Anderson are quoted with refer- 
ence to the findings of cardiac lesions identical with those found in rheu- 
matic heart diseases in cases of rheumatoid arthritis. (Ed. Note - This is 
indeed a very interesting observation and requires further study.) Clinical 
features of the disease were usually preceded by some illness, although not 
always streptococcal. He suggests that this illness may lower body resistance 
to the rheumatic infection. That abdominal pain is often an early symptom has been reemphasized by Langman (194l)> Berger (1945)* Davis and Rosin (1914;) 
and Jones (1944). He refers to the work of Hayes and Gibson (1942) with 
reference to the significance of subcutaneous nodules and also to that of 
Struthers and Bacal (1942) who suggest that their occurrence probably indi- 
cate recovery from the present attack, however, a poor ultimate prognostic 
sign. The sedimentation rate continues to be the best indication of activity 
of the disease* It is reported that about 50 per cent of cases recover with- 
out permanent cardiac damage and those cases with acute carditis have a poor 
prognosis* He cites the work of Gubner and Szucs (1945) who found ascorbic 
acid more effective than sodium bicarbonate in the reduction of the toxic 
effects of salicylates and that calcium double salt of benzoic acid and suc- 
cinic acid benzyl ester gave better results than salicylates. Many enthusi- 
astic reports of the efficacy of sulfanilamide as a prophylactic measure are 
quoted. 
Griffith (33) in a discussion on the newer concepts of rheumatic fever 
points out that rheumatic fever is currently being considered one of the 
collagenous diseases along with rheumatoid arthritis, periarteritis nodosa, 
lupus erythematosis, dermatomyositis and scleroderma. He considers rheu- 
matic fever a systemic, post streptococcal, nonsuppurative, inflammatory 
disease of a hypersensitive nature .-with protean manifestations of unpredict- 
able severity and duration. The syndromes differ one from the others of the 
group largely through the particular tissues involved and not because of any 
distinctive histologic picture. He presents evidence to show that acute 
rheumatic fever is a contact disease which is frequently associated with beta 
hemolytic streptococcus infections of types 6; 14; 17; 19; or 30. The ana- 
phylactic nature of the disease is stressed. He recommends the use of 
salicylates early in the treatment of rheumatic fever in order to block the 
hypersensitivity reaction. He cautions against the use of sulfonamides and 
penicillin in the treatment of rheumatic fever because they increase the 
state of hypersensitivity and thus increase the severity of the disease. 
Klemperer (34) recognizes the widespread implication of the connective 
tissue in the collagenous diseases and the possible significance of allergy 
in the causation of fibrinoid collagen alteration in these diseases. He is, 
however, reluctant to accept this allergic etiology solely on the histologi- 
cal features, esoecially since the classical manifestations of allergy are 
absent in the clinical course of these diseases. 
Peterman (35) has postulated that the connective tissue alterations, 
as well as the deleterious effects of focal infections and toxicity in gen- 
eral in rheumatic diseases, might be manifestations of an acute or chronic 
glycuronic acid deficiency associated with one of natures many protective 
mechanisms. He conducted toxicity tests of glycuronic acid salts in dogs 
and in one human without deleterious effects and then treated 52 arthritic 
patients with reported good results in all but eight cases. 
Discussing the etiology of acute rheumatic fever Gordon (36) relates 
that attempts to prove a bacterial etiology for acute rheumatic fever have 
been futile. He believes that a virus is the etiological agent and presents 
experimental evidence to support his views. 
Following a prolonged period of bed rest for the treatment of acute 
rheumatic fever Roche (37) has observed that upon resumption of physical 
activity a number ofpatients had arthralgic complaints which upon investi- gation proved to be unrelated to the attack of acute rheumatic fever. These 
cleared up with proper orthopaedic treatment. 
Two cases of pregnancy complicated by acute rheumatic fever who died 
following delivery are reported by McKeown (33). She studied six other cases 
of mitral stenosis in pregnancy in which the patients died from cardiac fail- 
ure. Microscopic evidence of recurrent rheumatic carditis and valvulitis 
was present in her two cases and in five of the six cases studied she con- 
cludes thats (1) Rheumatic heart disease even in its severest form may occur 
subclinically, (2) Recrudescences of rheumatic fever during pregnancy in a 
patient with a known cardiac lesion may not infrequently be the factor re- 
sponsible for cardiac failure, and, (3) The patient with active rheumatic 
carditis may die quite suddenly following delivery, the condition simulating 
acute obstetric shock. 
According to Rosenblum (39) the diagnosis of acute rheumatic fever is 
inadequate unless it includes the concept of activity or inactivity. The 
various manifestations of rheumatic activity are reviewed and are grouped 
in the order of their significance: (1) Activity positive, - carditis, in- 
cluding electrocardiographic evidence, nodules, erythema marginatum, chorea 
and polyarthritis,(2) Activity probable, - arthralgia and myalgia, pneumonitis, 
acute bronchitis, acute pleurisy, increased sedimentation rate and reduced 
vital capacity, and (3) Activity suspected, - fever, weight loss, abdominal 
and chest pain, rapid pulse, anemia and leukocytosis. 
Bach (i;0) in his recent edition of "Arthritis and Related Conditions" 
defines rheumatoid arthritis as a systemic disease whose etiology is un- 
known, but believed by some to be of infectious origin and in which a chronic 
progressive, nonsuppurative, deforming polyarthritis is the most apparent 
manifestation. The symptomatology is reviewed, the pros and cons of the in- 
fectious theory are summarized, and the influence of psychic distress, fatigue, 
hormones, nutrition, anemia, trauma, climate and constitutional background 
in the development of arthritis are discussed. He summarizes: "Rheumatoid 
arthritis notoriously strikes the asthenic usually in the twenties, who is 
poorly nourished and overly anxious, (young, tense, and skinny), who have 
been exposed to fatigue, psychic or physical trauma, bad diet or other sec- 
ondary factors either alone or in combination." 
In an excellent description of rheumatoid arthritis and rheumatoid spondy- 
litis Boland and Headley(Ul) consider both conditions to be variants of the 
same disease for whicHTgold is the best treatment in the former and x-ray 
therapy the treatment of choice in the latter. 
That rheumatoid arthritis may be precipitated by a gonorrheal infection 
is demonstrated in a case presented by Bock et al (U2) of a 29 year old male 
who developed polyarthritis two weeks following a gonococcal urethritis. 
The urethritis responded to penicillin therapy, but the general condition 
and arthritis did not, but rather progressed to manifest the findings ob- 
served in rheumatoid arthritis. 
Kelly (U3) points out that rheumatoid arthritis can be precipitated by 
an injury to a single joint. He reviewed the literature on the subject and 
presented ten additional cases. He refers to another 3h cases to show a 
striking preference for symmetrical patterns ahd suggests that the constitu- 
tional factor that favors the spread of the disease is a transient rather than a permanent condition of the organism. 
A study of the psychosomatic cause of rheumatoid arthritis was made by 
Johnson, Shapiro, and Alexander (14i)« Since the psychic factors are found 
so commonly in patients who do not suffer from arthritis, they conclude that 
additional etiologic factors still unknown must be postulated. 
Three cases of rheumatoid arthritis who developed lung lesions in the 
early active phase of the arthritis are presented by Ellroan and Ball (U5)# 
Two of these cases came to autopsy and revealed evidence of fibrosing pneu- 
monitis. They believe the lung lesions to be clinical manifestations of a 
generalized disease for which they propose the term "Rheumatoid Disease." 
Kersley and Desmarais (i;6) report that lesions have been discovered in 
rheumatoid arthritis which occur in any or all muscles of the body at any 
stage of the disease. They are also found in synovial membrane, the fibrous 
tissue stroma of fatty tissue and around the peripheral nerves. In about 
100 biopsies the histological picture has not been seen in any other than 
rheumatoid, non-specific, infective, or atrophic arthritis. They state that 
these nodules, though similar to those seen in rheumatic fever, can. micro- 
scopically be distinguished with considerable certainty. 
The characteristic necrobiotic nodules were found in the larynx, muscles, 
subcutaneous tissues, peritoneum, lungs, pleura, pericardium and myocardium 
of a 62 year old female with rheumatoid arthritis by Raven, Weber and Price 
0.7). 
The observation that subcutaneous nodules in acute rheumatic fever de- 
notes a grave prognosis lead Lucchesi and Lucchesi (U8) to study the signi- 
ficance of subcutaneous nodules in £5 cases of1 rheumatoid arthritis. They 
concluded that, contrary to the observations in rheumatic fever, the nodules 
in rheumatoid arthritis do not indicate an unfavorable outlook, any involve- 
ment of the heart, or any enhanced activity, intensity, or severity of the 
arthritis, and that they do not constitute any obstacle to treatment. 
In a study of 68 cases of periostites of the o« calcis Fang (Ii9) found 
that 73 per cent of them were suffering from rheumatoid arthritis• He con- 
sidered the pathological findings of bone destruction and proliferation 
comparable to that observed in Marie-Strumpell-disease. He concluded that 
periostitis of the os calcis in Chinese is not a separate entity, but an 
osteoperiosteal manifestation of rheumatoid arthritis. (Ed. Note - Many 
patients with rheumatoid arthritis complain of soreness about the heels. 
X-ray examination reveals the irregular areas of bone destruction and proli- 
feration as described in this article. Recently I have observed a periosteal 
reaction on the lateral surface of the middle third of the left radius in 
a patient with rheumatoid arthritis. Microscopic study of a biopsy revealed 
the picture of an inflammatory process with thinning of the bone trabeculae 
and the marrow spaces filled with fibroblasts and lymphoid cells.) 
Bywaters (£0) noted the radiological similarity between rheumatoid 
arthritis and pulmonary osteoarthropathy. He postulates that the periosteal 
changes may be due to the presence of an inflammatory edema with a high pro- 
tein content. Periosteal changes were not observed in cardiac and renal 
edema where the fluid protein was below ling per cent. Granlrer (51) studied the prothrombin time of fifteen patients of rheu- 
matoid arthritis treated with gold (Solganol 3) and liver extract for one 
year to determine if Vitamin K would be indicated, assuming liver damage due 
to gold. No increase in the prothrombin time was found. 
Unger, et al (52) believe that amyloidosis occurs as a complication of 
rheumatoid arthritis more frequently than generally believed. They report 
ten cases, four post mortem and six living out of 58 and 52 patients respec- 
tively, Prior to this only 1+0 cases have been reported. Hill (53) added 
another case. 
The importance of an adequate history, a thorough physical examination, 
with a few well chosen laboratory investigations, principally the sedimenta- 
tion rate and x-ray studies in the differential diagnosis of the arthritides 
have varyingly been discussed by Kinse11a (51+) > Bach (55), (58), Goldfain (56), 
and Collins (57)* Seth-Smith (59) ami Godfrey (66)• Seth-Srcith and" Godfrey 
strongly recommend the use of the standard hand radiograph as described by 
S, Gilbert Scott for the evaluation of arthritis. 
A study of rheumatoid arthritis in children was made by Sdstrom (61) in 
65 patients and Pickard (62), Pickard studied the records of about 200 
children suffering from rheumatoid arthritis of which 35 were followed long 
enough to observe the end results. They observed that the condition occurs 
not infrequently. About 5 per cent of all rheumatoid arthritis seen, as re- 
ported from several clinics, are under the age of 15 years, especially during 
the second and third years. Only three of Edstrom’s and five of Pickard’s 
cases displayed the clinical picture as originally described by Still with 
arthropathy, adenopathy, splenomegaly and hepatomegaly. Girls (71 per cent) 
were affected more often than boys (29 per cent) in Edstrom’s series. This 
sex difference was not so pronounced in Pickard’s cases. The onset of rheuma- 
toid arthritis in children differs from that in adults in that the larger 
joints are more often attacked. The lower extremities are involved most fre- 
quently, particularly the knees. Infection, trauma and allergy seem to play 
an inciting role. Heredity may play a part. The process frequently begins as 
a monarthritis, a factor responsible for many mistaken diagnoses. Visceral 
lesions occur more frequently than generally recognized, A moderate elevation 
of the sedimentation rate, a moderate hypochromic anemia and eosinophilia 
were observed, A tendency to flexion contractures is often marked, requiring 
physical therapy to keep the joints moving and orthopaedic measures to pre- 
vent and correct deformities. Rest and hospital care is a necessary part of 
treatment. The prognosis appeared relatively good in all cases except those 
of typical Still's disease. The average duration was from two to three years 
for those considered cured. 
A case of chronic polyarthritis in an eight month old male is reported 
by Tho (63), Only eight other cases of this disease under the age of one 
year Tiave been found in the literature. Another case of Still’s disease in 
a ten year old male was reported by Grieve (61+), This case was considered 
unusual because of a finding of polydactylitis with negative evidence for 
tuberculosis and syphilis. Two additional cases of rheumatoid arthritis with 
associated cardiac involvement, in males age 1+ l/2 and 5 l/2 years, were re- 
ported by Glick (65), The cases are discussed indicating the diagnostic 
problem posed By these two cases, (Ed, Note - These cases represent addi- 
tional instances of visceral manifestations in rheumatoid arthritis in chil- 
dren, ) 
66 Ankylosing spondylitis is discussed by Kuzell (66) and Rees, Albers and 
Nichols (67). The features of the disease are summarized# The etiology is 
unknown# It begins as an atrophic arthritis and secondarily there is ossi- 
fication of the adjoining ligaments# It involves the apophyseal articula- 
tions of the spine, the sacro-iliac joints, and sometimes the hips, shoulder 
and peripheral joints. The costovertebral joints also become involved# An 
antecedent genito-urinary infection may be a factor. Spondylitis occurs more 
frequently in females than generally believed# It is a disease of the young 
and active# The history of the patient reveals the presence of intermittent 
back pain or hip pain dating from childhood# The diagnosis is usually not 
made until the third or fourth decade# There is a marked elevation of the 
sedimentation rate and a moderate secondary anemia# The spinal fluid occa- 
sionally shows an increased protein content# X-ray changes are divided into 
three stages, the first stage of pseudo-widening of the joint space, the 
second stage pyknotic formation in the joint area, and the third stage loss 
of joint space and synostosis. Great symptomatic relief can be obtained from 
the proper use of X-ray therapy in conjunction with bed rest, braces, suppor- 
tive jackets, repeated transfusions of whole blood, physiotherapy, deep 
breathing exercises and nutritious diet# The differences between this condi- 
tion and rheumatoid arthritis are noted# Kuzell suggests research to deter- 
mine the culpability of virus as an etiologic factor# Of the 120 patients 
treated with X-ray therapy reported by Rees, et al, 80 per cent were im- 
proved# About 50 per cent noted improvement during the course of radiation 
therapy. Roughly 20 per cent of the 80 per cent improved had recurrences 
within one year# 
Douthwaite (68) states that in view of the difference in sex incidence, 
characteristic "bone changes and response to chrys©therapy as observed in his 
series of 692 cases of rheumatoid arthritis and 36 cases of ankylosing spondy- 
litis, he is unable to agree with those who regard the two conditions as one 
and the same disease. This view is also held by Buckley (69) who feels that 
the tendency of many to consider that ankylosing spondylitis is simply rheu- 
matoid arthritis affecting the spine has done much to retard progress in its 
study and to mask some of its most important characters. He believes that 
the disease begins in the bones and not in the joint tissues and that it is 
an infective or toxic osteopathy which may occur in two different forms of 
ankylosing spondylitis, the one described by Gilbert Scott as adolescent 
spondylitis and another which begins at a later age. 
Pesmarals (70) studied 2k cases of ankylosing spondylitis and found no 
correlation between the acid and alkaline phosphatase and the activity or 
duration of the disease in years. 
Some orthopaedic aspects of ankylosing spondylitis are discussed by 
Capener (71)* He advocates physiological rest, particularly on the Bradford 
frame for part of the day alternated with activity until symptoms subside. 
Surgically osteotomy of the spine as described by Smith-Petersen may correct 
some of the spinal deformity. To restore motion of the hip various recon- 
structive procedures are available; these include Whitman*s reconstruction, 
Colonna’s operation, Girdlestone»s hip excision, Jones subtrochanteric pseudo- 
arthrosis and Smith-Petersen*s mold arthroplasty. One case is reported bv 
Snow.(72) J 
Appelgren (73) reports four cases with intermittent swellings and pains in various joints with allergic characteristics. He suggests that the 
patient's present state could be a hyperergic phase in a chronic rheumatic 
condition of allergy. They may represent a transition between pure allergic 
arthritis and a usual chronic polyarthritis. 
A discussion of palindromic arthritis is given by Gryboski (7U) and 
Wolfson and Alter (75) each present a case. They summarize the condition 
as a syndrome of acute arthritis, periarthritis and para-arthritis that recurs 
in multiple, irregular, usually febrile attacks, and leaves no recognizable 
residuals in the affected joints. Routine laboratory tests are within nor- 
mal limits, Cholesterol and total lipoids are commonly elevated as is the 
sedimentation rates made during the attacks. The etiology is unknown, al- 
though allergy and psychic upsets have been suggested. Wolfson and Alter's 
case was in a U2 year old white female who had in four months 3U attacks of 
pain, tenderness, redness, swelling and stiffness of multiple joints. The 
attacks reached their height in from one to two hours and subsided promptly 
within three to twenty-four hours. Gryboski's case occurred in a 33 year 
old white female who had had erythema nodosum three years previously and 
extrapulmonary tuberculosis which had been treated with streptomycin. She 
presented the typical syndrome described by Hench and Rosenberg with a marked 
red nodular eruption over the acutely painful, tender, and swollen joints. 
There were multiple attacks. The sedimentation rate was elevated as were 
the blood cholesterol and total lipoids. X-rays revealed no changes. She was 
treated with slow intravenous drip of histamine and acid phosphate with re- 
fief of symptoms. 
An analysis of the literature on the etiology of fibrositis has been 
made by Valentine (76) which reveals that there is no unanimity among the 
many authors on the subject. He summarizes by stating that fibrositis seems 
to be a tissue reaction of varying pathology to several factors, largely 
from mechanical and physical and sometimes toxic causes. Some defect of 
circulatory functional response, probably in the peripheral reflex arc, may 
render the individual more liable to fibrositis. 
Scott (77) believes that some sort of infection is the cause of the 
formation of the fibrositic nodules. He considers the nodule a rheumatic 
scar in muscle which aches and burns with changes in weather as do other 
scars. He reports beneficial response to the local injection of essential 
oils, such as 3 per cent solution of benzyl salicylate in olive oil or Arachis 
oil, into the area of fibrositic activity. 
Beniaps and Russell (78) disagree with Dr. James Cyriax that symptoms 
commonly attributed to primary fibrositis are really caused by derangements 
of the spine. 
Osteoarthritis, one of the most prevalent rheumatic disorders, is dis- 
cussed by Bach and Waine (79), (80). They describe three pathological changes 
occurring at the same time: (1) degeneration of the cartilage, (2) hyper- 
trophic changes at the articular margins, and (3) condensation and increased 
calcification in the subchondral bone and inconstantly the synovia undergoes 
chronic hyperplasia. The changes usually begin in the second and third dec- 
ade of life and the alterations are irreversibly progressive with advancing 
age and become nearly universal in both sexes. The etiology is unknown; how- 
ever, there are a number of predisposing factors. The highest morbidity de- 
velops in patients of the fourth and fifth decades and more often in females than males* The clinical manifestations decrease in frequency during late 
life. 
Hall, Wade, et al (81) see the relief of pain as the main objective in 
the management of osteoarthritis rather than restoring painless movement* 
Osteoarthritis of the cervical spine which simulated coronary artery 
disease is reported in U3 patients by Davis and Ritvo (82). 
In an extensive study on Heberden*s nodes, a clinical characteristic 
of osteoarthritis of the fingers, Stecher (83) concluded that two conditions 
are necessary for their development. THe first, a hereditary susceptibility, 
and secondly, a normal nerve supply to the hands and fingers. Other factors 
which seem to be secondary include race, age, and menopause, according to 
Stecher and Beard (8U)* Stecher (8£) points out that the practicing physi- 
cians should "have a knowledge of the pathogenesis, occurrence, clinical signs, 
symptoms and futility of treatment of Heberden's nodes so that he can explain 
their significance to his patients. He will thereby be able to reassure his 
patients that although they have arthritis they have the mildest, least dis- 
abling and most painless form of the disease. 
Chronic idiopathic hypertrophic osteo-arthropathy first described by 
Sternberg in 1699 as a separate entity and elaborated on by Oehme (1919), 
Gronberg (1927) and others is reviewed by Camp and Scanlan (86), who report 
five cases. The etiology is unknown. It is not associated with primary 
diseases and occurs predominantly in males at puberty. It is characterized 
by clubbing of the digits, enlargement of bones and joints and thickening 
of the skin of the face. Its course is slowly progressive to deformity and 
disability, often extreme. 
Waxman and Geshelm (87) report the occurrence of 22 injuries to the 
knuckles-out of 52J injuries to professional and amateur boxers. In 12 of 
the 22 cases the diagnosis was contusion. In the remaining 10 cases a 
diagnosis of bursitis was made and confirmed by aspiration. Seven responded 
to conservative measures and three required excision. They reviewed the 
literature on 2? cases which occurred in a variety of occupations. In each 
instance it was considered post-traumatic* 
A discussion of gout is made by Bach (88), Hyers (89), and Hagemann 
(90), Sacasa (91), and Lindley and Middleton (92), who summarize the condi- 
tion in which there are sudden attacks of pain in joints which usually occur 
at night. The first attack usually occurs in the great toe (60 to JO per 
cent) in men (9£ per cent) after the age of 1*0 years. There is rapid in- 
crease to maximum disability with a hot, bluish, red, edematous joint. The 
attack ends abruptly and is followed by pain 'intervals, then by other 
attacks, eventually ending up as a chronic disease. Heredity is a predispos- 
ing factor. Trauma, infection, drugs, ketogenic diet and psychic disturbances 
are precipitating factors. It is associated with a high blood uric acid 
figure. Hagemann states this is due to increased urate formation. Sodium 
urate crystals are deposited in various tissues with resulting inflammatory 
and degenerative changes in about $0 per cent of cases. Punched-out areas 
appear in bone which Bach states can be differentiated because of size from 
rheumatoid arthritis. (Ed. note - The x-ray picture in g*6ut is not patho- 
gnomonic.) Olecranon bursitis, Achilles tendinitis and renal colic (10 to 30 per cent) 
are not infrequent manifestations. The chronic phase of gouty arthritis 
becomes established when residual joint abnormalities develop. This may 
be two to twenty years after initial attack. The disease occurs more fre- 
quently than generally believed. The diagnosis is aided by history, el- 
evated blood uric acid level, x-ray changes, satisfactory response to col- 
chicine and confirmed by the demonstration of urate crystals from tophi. 
Lindley and Middleton report a case in a 32 year old male. 
A case of unusual rapid progress in a male age 23 years is reported 
by Kersley (93)* Another case in a 36 year old male with multiple severe 
joint involvement and many features of rheumatoid arthritis is reported by 
Read and Buxton (9U)• Ankylosis developed in many joints. Later examination 
of bursae revealed urate crystals. The patient was treated with colchicine, 
orthopaedic surgery and physiotherapy with a return of function and ambulation. 
Horwitz (95) suggests that the presence of bone and cartilage debris 
in the synovium is a possible indicator of the early evolutionary stage 
of a neuropathic joint. 
A case of painless joint disease with the x-ray picture of a neuro- 
pathic joint in a patient with severe pernicious anemia, observed by 
Halonen and Jarvinen (96) caused them to study 52 other patients with 
pernicious anemia in which the test for syphilis was negative. They observed 
changes in joints, particularly in the knees. They considered the joint 
changes to be both clinically and radiologically of the type of neuropathic 
arthropathies. 
Spear (97) reports the development of a neuropathic knee joint seven 
years after the onset of diabetes in a 62 year old male in whom tests 
for syphilis were negative. 
A charcot joint secondarily infected by Staphylococcus aureus in a 6k 
year old male which failed to respond to intramuscular injection of peni- 
cillin was successfully treated by intra-arterial penicillin by Shaffer (98). 
The technique is described. 
A case of arthropathic psoriasis is reported by Senear and Griffith (99) 
in a 30 year old white male. Episodic stiffness and pain had occurred in 
multiple joints for fourteen years. For the past five months hyperkeratotic 
cutaneous lesions had been present on the tips of the fingers, toes and 
extensor surfaces of the elbows. 
Psychogenic rheumatism is discussed by Boland (100), (101). He states 
that physicians in general are not familiar with the fact that disabilities 
of the locomotor system frequently result from psychic causes. These are 
not infrequently diagnosed as arthritis and so treated by physicians who 
in so doing foster rather than alleviate the disability. He does not believe 
that mental disease is the cause of arthritis but may act as a precipitating 
factor. In a study of precipitating factors in 100 soldiers with rheumatoid 
arthritis an emotional upset was considered as a possible factor in only 
one instance. He defines psychogenic rheumatism as the musculoskeletal ex- 
pression of functional disorders, tension states or psychoneurosis. He reports an incidence of li**6 per cent in 7,000 cases of arthritis as seen in an Army 
rheumatism center during the war where it was second only to rheumatoid 
arthritis as a cause of admission* The diagnosis depends on: (1) absence 
of organic disease or insufficient disease to account for the disability, 
(2) qualitative functional characteristics of the disability, and (3) posi- 
tive diagnosis of psychopathology* The differential diagnosis most fre- 
quently must be made from primary fibrositis. 
Wright (102) also points out that psychogenic arthralgia will be diag- 
nosed more frequently and treated more satisfactorily if physicians are alert 
to its existence. He reports two cases of widely different character requir- 
ing different forms of treatment. 
CLINICAL INVESTIGATION 
A study of the agglutination test with hemolytic streptococci groups 
A, C and G, in 2i*l cases of rheumatoid arthritis with 80 per cent positive 
agglutination and in 900 control patients with a very low per cent of posi- 
tive agglutination is made by Kalbak (103)* In the control group of the 
cases of rheumatic fever 10 per cent gave positive agglutination, a high in- 
cidence per disease incidence in this group. He believes that the hemolytic 
streptococcus plays a dominant etiological role and that the reaction is an 
expression of chronic infection by hemolytic streptococci and is induced by 
a labile surface antigen (Y), The reaction reveals interesting points of 
resemblance between rheumatic fever and rheumatoid arthritis. 
Bertrand, Waine and Tobias (10U) studied the distribution of gold in 
the animal body by using a gold radioactive isotope in rats and rabbits. 
They found that the gold was taken up by various tissues of the body, in- 
cluding the central nervous system and ocular structure of the rabbit. It 
was taken up most markedly by the kidney and spleen. The time interval 
following injection had little to do with the values of any given tissue, 
which would seem to indicate that gold is held rather firmly by the respec- 
tive tissues once it has left the blood stream. The amount excreted after 
the fourth day is small. They found that the amount of gold taken up by 
chemically inflamed tissue in a chemically produced arthritis was signifi- 
cantly higher than in normal tissue. The same findings were noted in the 
inflammatory wall of a chemically produced abscess in muscle. The experi- 
ment was performed on one human arthritic patient where the synovium took 
up eighteen times as much gold as the skin which would compare to the values 
obtained for rat kidney. 
A study of the in vitro respiratory effect of gold salts on rat kidney 
by Block, Geib and Robinson (105) revealed that the in vitro inhibition of 
oxygen consumption with gold sodium thiosulfate is not lessened by the po- 
tential thiol compounds, cystine and methionine, nor by BAL or thiomalic 
acid which contain thiol groups; however, sodium thioglucose does lessen the 
inhibition of oxygen consumption. The effects of BAL and thiomalic acid may 
be marked by the fact that they, in themselves, produce inhibition of res- 
piration. The inhibition of oxygen consumption by gold chloride is appreci- 
ably reduced by thiomalic acid, BAL, cystine and sodium thioglucose, but not 
by methionine or cystine. When three thiol groups are furnished for each 
atom of gold, the reduction of inhibition is more clearly shown than when 
only one thiol group per atom of gold is present. A study of the use of polarized light on the fibrillar system of carti- 
lage in arthritis deformans was made by Lugiato (106) and compared with the 
use of ordinary stains* This fibrillar system is the supporting framework 
of cartilage, the early weakening of which indicates loss of cartilaginous 
elasticity. Loss of elasticity is followed by erosion, marginal prolifera- 
tion and in the later stages by invasion and replacement of cartilage by 
fibrous tissue. The degenerative process begins with the alteration of the 
fibrillar system of support. Degeneration increases with further alterations 
in the fibrillar system and ends with the destruction of the joint surface. 
A study of the changes in this fibrillar system is essential to an understand- 
ing of the changes characteristic of arthritis deformans, which has been made 
possible and readily carried out by the use of polarized light whereas it is 
difficult or impossible by other means. Polarized light can readily be used 
and is recommended in the study of the fibrillar system in other pathological 
conditions * 
Based on the belief that increased hyaluronidase activity is a possible 
cause of the breakdown of interfibrillar cement in rheumatic diseases and 
that high concentrations of salicylates in vitro inhibit hyaluronidase, where- 
as low concentrations of the biological oxidation product of salicylate, 
gentisic acid inhibits hyaluronidase, Meyer and Ragan (10?) employed sodium 
gentisate in rheumatic patients and found uniformly the same antirheumatic 
effect as salicylate without some of the disadvantages. 
Routti (108) studied the circulation in the forearm of eight healthy 
persons and eighteen persons with rheumatoid arthritis with the help of an 
air plethysmograph. He found very great individual variations in the periph- 
eral circulation in healthy individuals. The peripheral circulation of 
patients with rheumatoid arthritis had approximately the same rate as that 
of healthy individuals in a limb where there were no inflamed tissues, but 
was accelerated in those with inflamed limbs. 
Bartter, Forbes and Albright (109) found from metabolic studies that 
the administration of adrenocorticotropic hormone (A.C.T.H.) to patients with 
panhypopituitarism, acromegaly, osteitis deformans, and ovarian agenesis 
causes elaboration of an adrenal cortical hormone which inhibits the produc- 
tion of bone matrix by osteoblasts. 
Beneficial clinical effects with repeated blood transfusions are reported 
by Appelquist and Holsti (110) in 2k patients with severe rheumatoid arthritis* 
They recommend thalT it should be used before gold therapy in the routine treat- 
ment of this disease* They observed a general clinical improvement with a 
feeling of well being and increased mobility of the joints* When reactions 
due to transfusions occurred the improvements were most remarkable* The 
sedimentation rate is decreased and the hemoglobin values increased* They 
suggest that there may possibly be some antirheumatic factors in the plasma 
of healthy individuals* 
Simpson and Brooks (111) studied the effect of blood transfusions of 
whole~blood, concentrated red cells and plasma on the blood picture and 
general condition of patients suffering from rheumatoid arthritis. They 
found that the majority of rheumatoid patients had a normal total protein, 
a high fibrinogen, a normal albumin and a normal globulin value with a nor- 
mal a/g ratio. Foilwing transfusion with packed cells and whole blood those cases which showed abnormal protein values initially became normal. One of 
the cases returned to an abnormal value after one month. The remainder main- 
tained normal values for the one month period of observation. Some cases 
which were normal before transfusion became abnormal fourteen days after 
transfusion and a few with normal plasma proteins remained unchanged. Two 
cases transfused with plasma alone had normal figures before and after trans- 
fusion, They intend to study the effect of plasma alone on abnormal plasma 
readings. Blood transfusions resulted in a rise of the hematocrit and hemo- 
globin values. The crude and corrected suspension stability improved tempor- 
arily with the lessening of anemia and improvement of the plasma protein 
picture. At the same time the general condition of the patient improved 
markedly even though no immediate objective improvement was noted in the 
joints. They plan further studies to determine what constituents of blood 
is responsible for the improvements noted. 
TREATMENT 
A review of the literature published in 19U8 and written at this time 
is, of course, out-dated in many respects due to important and far-reaching 
advances in therapy and in clinical investigation in the field of Rheumatol- 
ogy. It was during the latter part of 19U8 that the initial work with “Com- 
pound E of Kendall’1, now known as Cortisone, was begun. It was also about 
that same time that other investigators began their work with ACTH or the 
adrenocorticotropic hormone. Other hormonal preparations and steroid com- 
pounds naturally have been used rather extensively in clinical investigation, 
which is still continuing on an extensive scale. These newer therapeutic 
procedures are still not available for general use. It is, therefore, essen- 
tial that the basic principles of therapy of rheumatic diseases, together 
with other therapeutic procedures of known value or of probable value, be 
understood. Treatment, therefore, is discussed under the various headings 
as follows: 
A, Rheumatoid arthritis involving peripheral joints. 
The management of these cases has been thoroughly discussed by Bauer 
(112), Norcross and Lockie (113), Wulp (llii), Pinckney (115»), Tegner (116), 
Bach (lI777ancr Bayles (l'l8), Essentially the basic program consists ofj 
TI Bed rest, including local rest for the involved joints and complete physi- 
cal and mental rest of twelve to sixteen hours per day, 2, Psychotherapy, 
3« Adequate analgesia afforded by aspirin or other salicylates, which is 
essential for rest and well being. It is well to remember the truism of 
Bench that flmusculoskeletal pain that requires narcotics is not arthritis1’, 
lu Directed exercises which are essential to improve and maintain muscle 
strength and tone and to maintain joint function, 5, Application of heat 
to actively involved joints which is beneficial in relieving pain and muscle 
spasm, 6, Proper support for joints allows reduction of muscle spasm and 
pain and prevents deformity. The prevention and correction of deformities 
are most important features in the treatment of rheumatoid arthritis, Meyer 
(119) warns that involved joints must not be kept in complete rest too long 
at a time less periarticular adhesions and fixation occur. Active and as- 
sistive exercises must be carried out daily. Elastic pressure bandages favor 
resorption and are comforting while rigid plaster bandages favor immobiliza- 
tion and congestion, 7* An adequate diet, adequate in calories, proteins. minerals and vitamins, is essential, and this may be supplemented by addition! 
vitamins when indicated. Bower (120) recommends the diet suggested by 
Fletcher of Toronto, consisting of maintenance protein, relatively low car- 
bohydrate and high fat, and where no gouty tendency exists nude ©proteins 
are liberally provided. This diet is supplemented by Vitamin B and wheat 
germ oil. Scully (121) discussed vitamin therapy in arthritis and concludes 
that vitamin therapy should be used only as an adjunct to other recognized 
methods of treatment. Concentrated Vitamin D in large doses has been re- 
ported as useful in some cases, but it is toxic and its routine use is 
not advisable, 8, Iron medication is useful in correcting the associated 
anemia, and whole blood transfusions are at times indicated and helpful, 
9, Removal of foci of infection is indicated in helping to improve the 
general physical condition, but not with the idea of the procedure being 
a curative one. 
In addition to this basic program, other therapeutic procedures are 
widely accepted and include: 1, Typhoid vaccine which is administered in- 
travenously at regular intervals, a total of four to six injections or more 
being given, (Ed, Note - This procedure has been used for many years and 
in our experience is of decided value in many cases,) 2. Streptococcus 
vaccines and foreign proteins which are reported as of value in some cases, 
3. Prostigmine given in injections of 1 cc of 1 to 2,000 solution or 15 to 
30 milligrams orally three times daily seems beneficial in relief of pain 
in some cases. Toxic manifestations from neostigmine have been reported and 
satisfactorily treated by atropine sulfate. A well controlled series has 
demonstrated little or no real value of neostigmine in the treatment of 
arthritis according to Ford (122). U. Electropyrexia has been recommended 
as an adjunct to all other forms of treatment of arthritis rather than to 
the exclusion of other forms of therapy by Hales (123) in his discussion on 
this form of therapy. 5* Acid azo compounds (Salazopyrin), according to 
Svartz (12U), produced beneficial effects in rheumatic polyarthritis, but 
his percentage of remissions and relief of symptoms was no more striking 
than the usual 60 to 75 per cent remission rate, 6, X-ray therapy was recom- 
mended by some authors in treatment of peripheral rheumatoid arthritis. 
(Ed, Note - Most authors agree as to its efficacy in rheumatoid spondylitis, 
but not in peripheral joint involvement.) 7. Autotransplantation of joint 
capsular tissue in an attempt to desensitize patients suffering from rheuma- 
toid arthritis afforded favorable results in Novotnyfs cases (125), but here 
again critical analysis reveals no increased percentage improvement over 
other types of therapy. 8, Procaine or novocaine by local infiltrations 
sometimes afford temporary relief, according to Pinckney (115) and Lipkin (126)1 
9. Gold therapy was considered by many as the best single method of treat- 
ment, but it should be employed as an adjunct to treatment, Norcross and 
Lockie (113) claim improvement in 75 per cent to 80 per cent of their cases, 
Wulp (llh) favors gold therapy as ”one of the most outstanding” methods of 
treatment and recommends smaller doses over a longer period of time followed 
by maintenance or booster doses every four to six weeks, Parr (127) reports 
a ’’cure” in 10 per cent of his cases and improvement in 75 per cent with 
gold therapy. He used sulfonamides before or concurrently with gold and 
believed the combination to be efficacious. (Ed, note - Sulfonamides are 
not considered of benefit in treatment of rheumatoid arthritis.) 
Brugsch and Manning (128) report definite improvement in 75 per cent 
of cases and degression of activity” in 58 per cent, Cohen, Dubbs and 
Goldman (129) report subjective and/or objective improvement in 90 per cent 
7^ of their 1*?£ cases and definite objective improvement in 6U per cent. Toxic 
reactions were encountered in 21 per cent of their patients and BAL was 
recommended upon the appearance of the first toxic symptoms. In 1*8 per cent 
of Snyder’s cases reported by Bach (130), gold salt therapy has been found 
effective. Toxic reactions have occurred in 16 to 1*0 per cent of cases. 
Aurol sulfide (colloidal) is less toxic, but is less effective, and is not 
recommended. Better results are obtained when gold is given early, but less 
dangerous methods of treatment are recommended unless the risk is considered. 
Toxic manifestations of gold poisoning are, according to Bach (131), gener- 
alized erythema, aplastic anemia, purpura haeraorrhagica, granulocytopenia, 
stomatitis, intestinal involvement, generalized hepatic impairment, edema, 
herpes, erythema nodosum, kidney impairment, multiple brain hemorrhages, etc. 
There is no warning period nor does there seem to be any relation between 
the amount of gold given and the severity of the ensuing reactions. These 
reactions may occur weeks, months or even a year after the last injection 
of gold. Kersley (132) states that gold therapy is still empirical, but when 
correctly administered to the selected case its beneficial effect greatly 
outweighs the risks. If gold cannot be continued, then other metals or vac- 
cines may be tried, such as sodium bismuthyl tartrate, copper salts or Alcup- 
rin administered intravenously or Dicuprene (Forestier) given intravenously 
or intramuscularly. The latter may cause slight dermatitis in some cases, 
but no other toxic signs. 
Boyles (118) recommends that chrysotherapy be instituted before irrevers 
ible joint damage occurs, but that on the other hand the patient should not 
be treated with gold until after other routine treatment of known value has 
been instituted for from three to six months. BAL has proved effective in 
his cases in counteracting the toxic reactions due to gold salt therapy and 
is given by intramuscular injections in 0,15 milligram doses four to six 
times daily and reduced in two to three days to one or two doses daily. 
Green and Russel (133) also found that gold dermatitis is satisfactorily 
relieved by the use of BAL, but following its use arthritic manifestations 
return promptly. Manifestations of tetany due to BAL therapy are probably 
due to depletion or unavailability of calcium or magnesium or both, according 
to them. 
Wright (13i*) concurs with Bayles (118) and Green and Russell (133) in 
that 'the' greatest benefit from chrysotherapy is derived by the patient with 
active rheumatoid arthritis, preferably in the early stages, and with the 
effectiveness and action of BAL in cases of toxity. He lists the following 
contraindications to the employment of gold: History of purpura, agranu- 
locytosis, renal or hepatic disease, pregnancy, hemophilia, severe diabetes 
mellitus, colitis, severe anemia or any hemorrhagic tendency, severe eczema 
or chronic dermatitis, severe bronchial asthma or any serious systemic dis- 
ease other than rheumatoid arthritis or psoriasis. 
The administration of gold should be combined with low grade fever 
therapy, 101°, for better distribution of the gold, and as an aid in elimina- 
tion of untoward reactions, according to Drewyer (135)* With this program 
he obtained 90 per cent ”remissions”. 
Forms of therapy, although of questionable value, but which may be help- 
ful according to Bach (117) are: Liver extract Bayles (113) states that one-fourth to one-half pound of raw liver given daily in one-half glass of 
ginger ale, tomato juice or grapefruit juice is thought to be helpful in 
cases of anyloidosis and rheumatoid arthritis , arsenic, strychnine, dilute 
hydrochloric acid, quinine as an analgesic and tonic, thyroid or thyroid and 
pituitary extract in some cases and estrogens in some cases. He further 
states that proper elimination is important and may be aided by bland or 
bulky diets as determined by barium enema studies and that ,fmild laxatives 
or colonic massage and irrigations may not be amiss”• 
Forms of therapy considered to be of no value in the treatment of rheu- 
matoid arthritis by various authors ares 1. Sulfonamides (Virkkunen (136) 
2. Iodine. 3* Sulfur. U. Aluminum subacetate (Blazer, Friedman and Stein- 
brocker (137) Aurol sulfide. 6. Penicillin (Goss, et al (13$ and Bach 
7* Bee venom. 8. Cobra venom is useful only in cases of arthritis 
due to malignancy where it is useful in relief of pain. 9. Hypertherm. 
10. Streptomycin. 11. Neostigmine. 12. Reticular cytotoxic serum. 
B. Rheumatoid arthritis of the spine or rheumatoid spondylitis. The 
general care of the patient is as important~Tn spinal arthritis as in cases 
with peripheral joint involvement. Most of the recognized principles of 
treatment as discussed above apply equally in the case of the spondylitic. 
Adequate rest, a high caloric diet supplemented with vitamins, improving or 
restoring the patient’s morale, the removal of foci, the use of aspirin or 
sodium salicylate in adequate doses for relief of pain and in obtaining re- 
quired rest, deep breathing and postural exercises, which should be given 
three times a day, fracture boards used under the mattress, only a small 
pillow permitted, if at all, hyperextension carried out thirty minutes out 
of each day, artificial supports dispensed with unless absolutely necessary 
to maintain posture and X-ray therapy for controlling the pain are accepted 
principles of therapy outlined by Pinckney (ll£), Bach (117) and Toone (IliO). 
The technique of X-ray therapy advocated by Smyth, Freyberg and Lampe in 
191+1 is the one most generally used. Gold is of no benefit. Concentrated 
Vitamin D and parathyroid preparations should not be used and will only lead 
to generalized osteoporosis and may result in pathological fractures. 
Williams (H4.I) states that the original method of X-ray therapy of Dr. 
Gilbert Scott is now accepted as outmoded by a newer, more intensive therapy. 
The joints of the spine, the hips and shoulders, the ischial tuberosities, 
crest of ilium, sternoclavicular and costosternal joints are treated with 
alleviation of symptoms. Inflammatory tissue or granulation tissue is radio- 
sensitive and resolution can be induced by X-rays and muscle spasm is re- 
lieved. According to Borak (11+2), (U+3), in the early or first stage of the 
disease active motion as t¥e?lexly,t limited to avoid pain produced by inflam- 
matory processes in the synovia. Small doses of X-ray, £0 r, are effective 
in this stage, and if this is not effective, it must be assumed that a more 
advanced stage is present and from 300 r up to 1200 r may be used within a 
period of two to three weeks. 
In the second stage active and passive limitation is associated usually 
with narrowing of the joint spaces and some bone destruction. If a dose of 
r is given in a period of two to three weeks, pain gradually decreases, 
but if the dose is too small symptoms may relapse. ’’The extent of improvement 
is proportionate presumably to the destruction of granulation tissue.” 
76 In the third stage no active or passive motion is possible, but pain 
can be influenced by 1600 r given over a period of ten days. The percentage 
of favorable results increases in proportion to the dosage applied* 
Williams (liil) reminds us that X-ray therapy in spondylitis is not with- 
out danger* "He states that greater skin reaction occurs over bony prominences 
and no case should be taken beyond a dry scaly desquamation stage. Since 
a large volume of the bone marrow is involved and the heart and circulating 
blood is exposed, leucopenia, chiefly affecting polymorphonuclear cells and 
later lymphocytes and still later red blood cells may develop. Constitutional 
symptoms of lassitude, nausea and vomiting may occur. In treating males the 
testicles should be shielded by lead. In the young females artifical meno- 
pause may occur and chromosome abnormalities, which in later generations cause 
developmental abnormalities, may be present. The effect of X-ray therapy on 
the disease is: Pain is decreased or abolished; paravertebral spasm is re- 
laxed; stiffness is lessened and spinal motion and chest expansion is in- 
creased; the whole mental outlook changes; there is a gain of weight; and, 
the sedimentation rate is lowered. 
A second course of treatment should not be considered in less than six 
months • 
Radioactive thorium treatment has been used in spondylitis with reported 
comparable results (• 
C. Osteoarthritis or degenerative joint disease. 
With reference to the treatment of osteoarthritis, the situation is not 
a very satisfactory one according to Fletcher (li*5)• He very appropriately 
states that ,lrest,, is the primary treatment of choice. He recommends adjust- 
ment of posture as of obvious importance, since joints put at a mechanical 
disadvantage tend to show degenerative changes after a varying length of 
time. Correction of mechanical defects are therefore essential. He further 
states that heat, preferably in the form of diathermy, is the best form of 
physiotherapy. In hip involvement at least one hour a day of diathermy should 
be given five days each week. Weakness and wasting of muscles are treated 
by non-weight bearing exercises. He further recommends injection of joints 
with various drugs or chemicals, especially 0.5 per cent procaine, but cautions 
as to the extreme care concerning sterility in-technique. In some cases he has 
found manipulation with stretching of the capsule, under anesthesia, of value. 
He refers to vitallium cup arthroplasty as a popular operation and also to 
joint debridement as described by Magnuson in 19U1. 
By far the majority of articles dealing with treatment of osteoarthritis 
published in 19UB dealt with the injection treatment of this disease. 
Waugh (1U6) stated that in rheumatoid arthritis the synovial fluids be- 
came relatively alkaline with a p H around 7*6 and in osteoarthritis the syno- 
vial fluid approached a p H of 8. To his cases ho gave injections weekly 
or fortnightly using a stable solution of procaine lactic acid at a p H of 
5.0, injecting 1 ml into interphalangeal joints, 2 to i* ml in the wrist and 
shoulder joints, 5 to 10 ml in the knee and 10 to 15 ml in the hip. Before 
injections the joints were aspirated, and afterwards manipulations and fre- 
quent active exercises were carried out by the patient. His results in osteoarthritis and the less active forms of rheumatoid arthritis were “most 
encouraging” in that greater mobility and relief of pain ensued. In patients 
with bilateral involvement, more marked improvement was seen in joints treated 
by injection plus physical therapy as compared to the contralateral joints 
treated by physical therapy alone. 
Baker and Chayen (11*7) described the intra-articular injection treatment 
of osteoarthritis, and of $2 cases, 16 patients were "greatly improved” and 
only 13 showed no improvement. It was found that lactic acid solution, a p H 
adjusted procaine solution and normal saline all seemed to have about the 
same effect, namely an increased range of motion allowing for increased exer- 
cise and movement. They believed that the “lubricating effect” of the in- 
jected fluid was of importance and that fluids of higher osmotic pressure 
and viscosity might afford more benefit. Following the procaine effect from 
the injections, active non-weight bearing exercises are required; symptoms 
were relieved for about two weeks and then another injection was given. 
Holmes (H48) described improvement in osteoarthritis of his own hip 
attributedto treatment by Waugh. In 1936, after riding and hunting, he 
experienced a painful left hip and had to cease riding in January 1939* By 
19U5> he was unable to walk but for a short distance due to severe pain. 
Roentgenographic examinations revealed "severe osteoarthritis, left hip - 
too dense for detail". After the third of ten injections the pain was de- 
cidedly less and exercise movements were less painful. His treatment was 
begun in June 19U7 and ended in December 19U7* at which time he was able to 
stand for three to four hours. 
Nicholson (1U9) demonstrated with radiopaque dye that only one out of 
twenty-five injections of procaine lactic acid was actually given within the 
joint space itself in three patients with osteoarthritis of the hip. However, 
two of the patients showed improvement which was attributed to the injections. 
He criticized Waugh1s observations referable to the p H of synovial fluid on 
the basis that the p H of the fluid in vivo and in vitro may not be comparable 
due to rearrangement of gasses between the fluid and the environment and sug- 
gested that more accurate determinations are needed. 
Graubard, Kovacs and Ritter reported on the use of intravenous 
procaine injections in nine cases of osteoarthritis, four of rheumatoid arthri- 
tis, one of traumatic arthritis and one of Legg-Perthes disease (a total of 
fifteen cases). A total of 137 injections were given using four milligrams 
of procaine per kilo of body weight dissolved in isotonic saline solution to 
make 0.1 per cent solution (1-1000). The total dosage was administered over 
a twenty minute period and the injections repeated at weekly intervals, de- 
pending upon the general condition of the patient. Relief of pain, loss of 
muscle spasm and in some cases increased mobility were noticed within a few 
minutes. They caution against too rapid administration or the use of too 
concentrated solutions to prevent occurrence of toxic manifestations or con- 
vulsions, and found that injection of soluble barbiturates was effective in 
relieving the latter, and that the use of epinephrine, camphor and oxygen 
is indicated for respiratory or circulatory collapse. They further state 
that this treatment may be contraindicated in cardiac disease, particularly 
if digitalis is used. They rationalize this form of therapy upon the elimina- 
tion of the reflex cycle initiated by the irritative process after procaine 
infusion resulting in the diminution of vascular spasm and improvement in circulation which is followed by the relief of pain and increase in mobility. 
They further state that gold therapy is of little or no value in destructive 
arthritis of the hip, that the physiotherapist can offer much in the way of 
relief, but this is temporary and exacerbations have been induced, that sur- 
gically the results are not persistently good and that all cases cannot be 
considered for arthroplasty; that neurectony of the obturator nerve has not 
produced encouraging results; that radicotomy of the third, fourth and fifth 
lumbar roots is of doubtful value; and, that although fifty to sixty per cent 
of the cases treated by intra-articular injections of lactic acid reportedly 
improve, that these figures have not been confirmed. They believe, therefore, 
that the intravenous administration of procaine obtains more persistent good 
results than the other methods employed and that it is an important adjunct, 
not a cure, in the management of destructive arthritis of the hip. 
Borak (l£l) states that in osteoarthritis, particularly of the knees, 
hands and hips, something may happen to a degenerative joint of long standing 
and of relative freedom of symptoms and the joint becomes hot, swollen and 
painful. In this "inflammatory type" X-ray is better than in any other type 
and he states 100 r calculated at the joint and given at intervals of one 
to two days produces quick remarkable relief. A few larger doses are then 
given to prevent recurrences. In the nfibrositic type" (commonest type) in- 
volving the knees and fingers, periarticular fibresitis involves the joint 
capsule and muscle stiffness ensues, which does not yield to X-ray as readily, 
Larger doses, to 200 r, calculated at the joints and given six to eight 
times at intervals of two to four days will be required. He states that in 
the "hyperplastic type" 1000 r given within two to three weeks, a single dose 
being not less than 200 r, should be given. He further states that in no 
stage is it ineffective. 
In "discogenetic disease", exemplified by the so-called hypertrophic 
arthritis of the spine, true symptoms are due to encroachment on the fora- 
mina with pressure on nerves and thus nerve root symptoms. Mild edema in 
connective tissue in such a foramen may cause considerable symptoms. Borak 
states that X-ray is often helpful if the diagnosis is correct and the proper 
part treated, and $0 to 200 r calculated at the level of the intervertebral 
foramina given three or four times at intervals of from two to three days 
in an early stage. In the advanced stage he gives six to eight treatments 
and in the very advanced stages the single doses amount to 300 r. 
D. Treatment of miscellaneous forms of rheumatic diseases. 
Lipkin (lp2) states that procaine injections may be indicated in cases 
of: 1. Localized fibrositis. 2. Non-suppurative bursitis. 3. Brachial 
or sciatic neuralgia, k• Traumatic disorders (sprains, fibrositis or arthri- 
tis). 5>. Osteoarthritis. 6. Rheumatoid arthritis (inactive). 7* Specific 
infectious arthritis (inactive). 8. Coccygodynia after careful study has 
ruled out the presence of visceral disease. He lists the contraindications 
of: 1. Known sensitivity to procaine. 2. Extremely apprehensive or neu- 
rasthenic individuals, 3« Uncontrolled diabetes, i*. Sites of or near in- 
fected areas. He recommends preliminary sedation with 0.1 gm of sodium 
amytal one hour prior to injections and the dosage recommended is from 3 to 
30 cc in a 1 per cent solution of procaine. In local fibrositis he injects 
£ to 10 cc, in brachial plexus blocks 10 to 20 cc and in sciatic blocks 20 to 30 cc. The injections are given at daily to five day intervals. Of his 
100 patients "38 recovered completely, 1*2 showed marked improvement, 6 failed 
to respond and in 5 the results were unknown". No supplemental therapy other 
than exercise within tolerance was given. He recommends this form of therapy 
as an important adjunct and not a "cure" in that it prevents atrophy by allow- 
ing increased motion by relaxing muscle spasm and relieving pain. 
Mayer (153) described the use of a plaster bed and traction to a lower 
extremity with "infective arthritis of the hip joint", a method which maintains 
fairly simple and easy movement of the patient for therapy and nursing care. 
Borak (151) states that in para-arthritis ("tendogenetic disease") ex- 
emplified by the "frozen shoulder" originating from calcific tendonitis even 
though considerable calcium may be present and if in the acute stage, the 
condition will respond favorably to X-ray therapy within a few weeks. Chronic 
cases, even though the calcium deposits may be small, may take a long time 
for improvement to occur. Asymptomatic calcium deposits will show no response 
to X-ray therapy. He states, therefore, that X-ray affects the underlying 
inflammatory process. In the non-calcified variety of peritendonitis, bur- 
sitis or periarthritis the principles of treatment are the same. 
PHYSICAL THERAPY 
The various modalities employed by physical medicine in the treatment 
of arthritis are discussed by Hansson (15U)« He emphasizes the importance 
of maintaining or reconstructing proper body mechanics and posture in the 
arthritic patient, and states that massage and exercise are indispensable 
in their management. 
Yfalker (155) stresses the importance of gradually increasing exercises 
in the chronic ambulatory stage of rheumatoid arthritis. After the disease 
becomes quiescent, he sees a need for gentle manipulation under anesthesia. 
In the treatment of osteoarthritis a more vigorous regime of stretching and 
manipulation results in more striking results than in the rheumatoid patient. 
Moor (156) reminds us that in the past rest for arthritic joints has 
been overemphasized and cites the need for a balance between rest and exer- 
cise of the joints. Heat, massage and vaso-dilating drugs by iontophoresis 
are valuable adjuncts. 
Kistler (157) sees physical medicine as the one most potent single 
weapon in tKe treatment of arthritis. He recommends daily heat, massage, 
occupational therapy and exercise with emphasis on the latter. These exer- 
cises should be simple, practical and easy to perform. 
A list of practical and easily performed exercises are discussed by 
Osborne (158). 
Stengel (159) reports satisfactory results in 90 per cent of 1*00 rheuma- 
toid patients treated with iontophoresis using magnesium sulfate, sodium 
salicylate, histamine and mecholyl. He believes that an elevation of the 
sedimentation rate occurring while a patient is receiving physiotherapy is 
a contraindication for that particular modality. Brokaw (loO) recommends the employment of occupational therapy as soon 
as the heat and swelling in the joints begin to subside and the sedimentation 
rate starts to drop toward normal. He cautions against substitution of 
muscles and stresses the importance of correct posture and maximum position 
of joints for function. He advocates many of the common household tasks as 
a means of exercise. 
In a discussion on therapy, convalescent care and rehabilitation in 
rheumatic fever Kresky (161) recommends: 1, Bed rest and adequate drug 
therapy during the acute phase. 2, Slow, careful convalescent care with 
an attempt at occupational rehabilitation. 3. A cheerful, optimistic atti- 
tude during the acute attack and during convalescence in order to prevent 
the development of a ’’cardiac neurosis”, U. After recovery, a complete 
occupational re-evaluation and re-education in terms of his cardiac dis- 
ability. 5. Immediate preventive measures at the onset of a cold, sore 
throat, an attack of tonsillitis or sinusitis, 6. Periodic check-ups to 
re-evaluate both the cardiac and the occupational status. 
ORTHOPAEDIC TREATMENT 
A review of the literature on arthritis reveals that the rheumatologist 
is working more and more in closer conjunction with the orthopaedist. 
Law (162), (163), (I6I4) emphasizes the importance of undertaking recon- 
structive surgery before joint destruction is complete and before serious 
atrophy of muscles and ligaments has developed. Orthopaedic measures are 
carried out simultaneously with other forms of treatment. Treatment is directed 
toward the relief of pain, arrest of disease, maintenance and restoration of 
function, and the prevention and correction of deformity. During the acute 
stage of rheumatoid arthritis rest and splinting are employed, and as the 
inflammation subsides physical therapy is increased. Milder deformities 
are corrected by wedging casts and manipulations under anesthesia. He dis- 
cussed the indications for operative measures, such as: excision of the 
acromion process in rheumatoid arthritis of the shoulder joint; excision of 
the head of the radius and subtotal synovectomy in some cases of arthritis 
of the elbow; arthroplasty of the elbow; excision of the distal end of the 
ulna to improve radio-ulnar function; capsulotony or capsulectomy with or 
without resection of the interphalangeal and metacarpophalangeal joints of 
the hands and feet; and, arthroplasty of the hip joint by the Smith-Peterson 
vitallium mold technique. He states that arthroplasty of the knee is not 
too satisfactory, but offers some promise. Arthroplasty of the temporo- 
mandibular joint may be helpful to relieve pain and improve motion. In 
ankylosing spondylitis spinal osteotomy has beneficial effects. 
Similar principles of treatment are outlined by Young (165). 
Bach (166) in his chapter on ’’Orthopaedic Intervention in Arthritis” 
discusses generally the indications for synovectomy, capsulotony and arthro- 
plasty in rheumatoid arthritis and for fusions and reconstruction operations 
cn the hio and knee in osteoarthritis. 
Batchelor (16?) reports that excision of the femoral head and neck 
followed by osteotomy can be relied upon to give a painless stable joint with 
?£° to 90° range of motion in unilateral traumatic and degenerative osteoarthri- 
tis, ununited fracture of the femoral neck and fracture-dislocation of the hip. In ankylosing spondylitis and rheumatoid arthritis, excision 
of both hips followed by osteotomy has restored to limited activity patients 
formerly bedridden. He recommends the procedure also in chronic suppurative 
arthritis• 
Manipulative treatment and supportive Orthopaedic measures are dis- 
cussed by McCauley (168) who stresses the importance and preference of active 
exercise over passive exercise in the movement of arthritic joints. Occasion- 
ally in selected cases he sees a need for careful manipulation under anesthe- 
sia which may be followed by excellent results. He also describes the optimum 
position for joints at rest and supportive measures to maintain these positions 
at rest as well as in the ambulatory stage in the treatment of arthritic 
joints. BIBLIOGRAPHY 
1. Bach, T. F.: History of arthritis. Arthritis and Related Conditions, 
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paedic measures. See reference No. 1, pp. 296-310, 19U7 SECTION 6 
POLIOMYELITIS 
Prepared by 
Knox Dunlap, Colonel, MC, USA 
and staff 
A complete survey of poliomyelitis in all its aspects was conducted 
by representatives of 60 countries, in a week-long conference of the First 
International Poliomyelitis Conference, sponsored by the National Foundation, 
12 July in New York City. The Conference is completely reported by 
Tenbrinck (1). Her material makes a source for the best current thought on 
this subject* 
Green (2) reviews our present knowledge regarding poliomyelitis* Many 
new types of treatment have been introduced and a few have merit, but no 
treatment changes the progress of the acute stage greatly. Much publicity 
has been given the disease by an organization that is nation-wide in its 
scope* The information given the public is intended to be scientific, but 
this is not always the case* One feature of the epidemiology should be 
emphasized: The increased incidence of bulbar poliorqyelitis in patients 
shortly after tonsillectomy* Tonsillectomy during an epidemic is undesirable* 
Infantile paralysis is characterized by an acute illness that, in its 
first phase, may be non-specific but soon causes symptoms referable to the 
central nervous system. If one pictures a disease in which one muscle group 
may be paralyzed and the opposite groups in painful spasm, it can be appre- 
ciated that deformity may result. The effect on the central nervous system 
is wide-spread, but most damage is done to the anterior horn cells. It 
should be emphasized that the spasm is not the most damaging effect of the 
disease, as proposed in the Kenny concept, but it is a symptom that, with 
sensitivity, tends to be deforming in the early stages. Curare and prostig- 
mine have not been of particular benefit in the treatment of the disease. 
The treatment is carried on best by dividing the disease into three stages. 
During the acute stage, the patient should not exert himself. Bulbar 
involvement is indicated by such signs as difficulty in swallowing, changes 
in the voice and irregularity of respiration. In the bulbar type, the head 
is kept dependent and manual aid to respiration is given, if necessary. In 
spinal respiratory type, the use of the respirator is indicated. 
Convalescent stage: Physiotherapy is increased and hot packs to muscles 
in spasm are used. The parts are kept in good position with feet held at 
right angles. A muscle evaluation should be made after the temperature has 
been normal for I48 hours and this examination should be repeated at regular 
intervals. After the insensitive phase of the convalescent stage is reached, 
actual stretching of the contracted parts is sometimes necessary. 
Chronic stage: Physiotherapy is continued with the hope of complete rehabilitation of the patient. If surgery is necessary, it is continued as 
an adjunct. 
Most of the clinical observations of poliomyelitis have been limited 
to that relatively rare form of the disease which results in residual paralysis. 
Even here no controlled observations have been published which enable one to 
say whether a great variety of symptoms are really typical of this disease. 
Current articles list diarrhea, sore throat, running nose and cough as symp- 
toms, but offer no proof. 
A group of 6h cases of subclinical poliomyelitis, proven by the finding 
of the virus in throat or stool culture; 33 cases of clinical poliomyelitis, 
manifested by paresis, paralysis, reflex changes, etc.; and cases, classi- 
fied as non—contact or control cases, in which stool and throat cultures 
were negative for the virus, were studied by Casey and Fishbein (3)« The 
incidence of the various symptoms and signs in the 15>7 control children was 
compared with the incidence of various symptoms in the 6k children with sub- 
clinical poliomyelitis. Fever, headache, constipation and drowsiness occurred 
significantly more often among the children with subclinical poliomyelitis 
than among the control group. Noteworthy was the fact that sore throat, 
diarrhea, running nose and cough were not significantly related to the symp- 
toms of subclinical poliomyelitis. The symptoms in the patients with clinical 
poliomyelitis were then compared with those in the control group. Again run- 
ning nose, diarrhea and cough were not symptoms of clinical poliomyelitis, 
but sore throat and leg ache were. The symptoms of headache, vomiting, cons- 
tipation, drowsiness and mild fever were of statistical significance as in 
the subclinical form. The difference vras that headache, vomiting, constipa- 
tion, drowsiness, fever and leg ache were more often encountered in the 
clinical than in the subclinical form. It is interesting sore throat had 
no relation to symptoms of the patients with the subclinical form of polio- 
myelitis but was often present in children who had stiff neck, stiff back, 
head drop and paralysis. 
The whole diagnostic problem of poliomyelitis is presented by Caughey 
(U). He includes the incidence and mortality rates in New Zealand and the 
present concept of the disease. The author describes the following types 
of cases; The healthy carrier, the convalescent carrier, the abortive case, 
the pre-paralytic case, and the paralytic case. He discussed the diagnosis, 
the subjective and physical findings, the clinical pathology and the dif- 
ferential diagnosis in each stage. 
As part of a symposium on poliomyelitis, Robertson (5) briefly discusses 
the symptomatology, existence of the healthy carrier state, and the thera- 
peutic use of various drugs, as well as some inherent constitutional charac- 
teristics of the paralytic patients which tend to pre-dispose the individual 
to the disease. He cites the work of W. Lloyd Aycock, who found that %1% 
of the poliomyelitis victims gave a positive family history of the disease, 
whereas such a history was obtained on only of the unaffected individuals. 
The author also discusses the observations of Draper in 1916, as well as his 
own, that the poliomyelitis patients have certain anthropometric characteris- 
tics, and a tendency toward obesity, eunuchoidism or hypogenitalism. 
A clear and concise presentation of the known facts and current theories 
of all aspects of acute poliomyelitis (both spinal and bulbar) is outlined by Miller (6)• 
Keiser (?) reviews a few of the facts known about poliomyelitis* It 
is pointer”out that there are some 16 strains of the virus, that the virus 
is taken into the body through the GI tract and the treatment is symptomatic* 
Russell (8) establishes two premises, based on a study of 5U patients 
with poliomyelitis, first, that poliomyelitis may be diagnosed on clinical 
findings before the appearance of paralysis, and second, that physical ac- 
tivity in the pre-paralytic stage increases the incidence of paralysis. He 
considers the so-called meningitic symptoms of most significance since they 
are almost universally present in the pre-paralytic stage. They suggest in- 
volvement of nerve roots rather than the meninges, and consist jf pain in 
the head, neck, and in the dorsal, lumbar or sacral spine, in addition to 
the scapular region, thighs, or lower chest, singly or in combination. These 
pains vary from mild to severe. Fever may be absent. The meningitic symp- 
toms may abate and the patient may even be subjectively improved juso prior 
to onset of paralysis. A review of the patients’ records indicates that those 
who indulged in physical activities during the pre-paralytic stage tended 
to show a greater incidence of subsequent paralysis, and also had a greater 
severity of paralysis. He concludes that complete physical rest in bed dur- 
ing the whole of the pre-paralytic stage helps protect the patient from 
severe paralysis as much as, or more, than any other single factor. 
A report based on 100 cases of acute poliomyelitis admitted to St. Lukes 
Hospital, Kansas City, Missouri, during the summer and fall epidemic of lpl;6 
is presented by Jones and Dickson (9)• Prostigmine proved of little or no 
value in the treatment of acute poliomyelitis, and the side effects were 
objectionable. Curare had little or no beneficial effect on paralyzed mus- 
cles, but relieved pain, muscle spasm and discomfort, and was especially 
valuable in cases of laryngeal and intercostal paralysis. 
Arvola (10) gives his observations of the follow-up examinations of 11? 
poliomyelitis patients with paresis, who v/ere admitted to the City Hospital 
for Communicable Diseases in Helsinki from 1937 to 191*2. His series, ad- 
mittedly small, led to the following conclusions: Adults now contract the 
disease as often as children, but in children the disease is milder and the 
prognosis better. The mortality is higher in adults, lowest in the group 
under the age of seven, and higher among males than females. Within 
years, 17$ of the paretic cases had completely recovered, over 1*0$ were 
practically well, 60$ had slight defects, and only U*$ were seriously dis- 
abled. 87$ of patients over 18 were capable of self-support. The milder 
the paresis originally, the greater was the tendency toward muscular recovery. 
In patients under 1$, the greater the original paresis, the greater the 
tendency to limb shortening. Serious paresis always resulted in shortening, 
mild paresis never. Joint contracture and flaccid joints were the usual de- 
formities in children, while scoliosis was frequent in adults. Continuous 
medical supervision gave the best results. 
The results of a survey of the poliomyelitis admissions to 270 hospitals 
of England and "Wales during the period 1 Jan. toll Oct. 19U7 is given by Brad- 
ley and Gale (11). The survey includes a total of 1*,717 cases, of which one- 
third were under 5 years, one-third between 5 and V? years, and the balance 
97 over 15 years. The mortality of the series was 7*6$ (360 cases). It was 
greater in older patients. 3U61 cases (73*3%) showed paralysis, of which 
2,976 had involvement of the limbs or trunk, and 1*85 had involvement of the 
cranial nerves. 1097 patients had no paralysis, but were diagnosed on the 
changes in the cerebro-spinal fluid or on clinical grounds only. Of the 3138 
non-fatal paralytic cases, 1*1.1$ were mild, 38.5$ were moderate and 20.1*$ 
were severe. Respirators were used in the treatment of 310 patients of which 
93 are likely to require this mechanism permanently. 
In an account of the epidemic of poliomyelitis in the James town, N. Y. 
area, during 19l*7> Clark and Furlong (12) give their experience with 71* re- 
ported cases in the hope that it will be helpful to individuals dealing with 
a similar situation in their own localities. This is a very detailed report 
and comes to the following conclusions: 1. Exercise during the prodromal 
period makes the prognosis worse. 2. During an epidemic, persons with 
11grippe-like” symptoms should be put to bed. 3* Fatigue, over-exercise, 
trauma, infection and chilling are related to the onset of clinical cases. 
I*. Patients should not be up until tightness of the muscles has been re- 
lieved by rest or physical therapy. 5* There is no correlation between the 
protein in the spinal fluid and the severity of the disease. 6. Antispasmo- 
dic drugs have been disappointing in their effects. 7« The number of cases 
in the first few weeks is an index of the severity and duration of an epidemic. 
Edwards (13) analysed ll*9 fatal cases of poliomyelitis. He gleaned the 
series from cases of poliomyelitis in military personnel in the United States. 
The average mortality rate for army cases from 191*0-191*5 was 17$ as compared 
with a rate of 9$ in the general population. This is ascribed to the dif- 
ference in age groups. Of the li*9 cases, 8 were negroes. One hundred twenty- 
two cases were bulbar spinal, 21* bulbar, and 3 encephalitic, li* cases died 
of respiratory failure. Stiff neck was more frequently seen than stiff back. 
122 cases developed paralysis of extremities. Paralysis of intercostals 
(69/£) was more frequent than that of diaphragm (1*2$). Of the cranial nerves 
the 10th was involved most. Dysphagia was observed in 93 patients. In 87$, 
paralysis developed within h days after the onset of symptoms. 93 patients 
showed normal reflexes. As the bulbar cases showed ascending signs, the deep 
reflexes disappeared. Spinal fluid findings were often incomplete. It was 
clear in 82%, and with a cell count between 100-500 wbcs in 1*5$ • Chemistry 
on the spinal fluids was within established limits. Sedimentation rates 
were elevated in 78$. In fatal cases, death occurred most commonly between 
the 3rd and l*th days. The treatment of the disease did not vary from es- 
tablished standards. Misdiagnosis included tetanus, hookworm, battle fatigue, 
sand fever and malaria. 
McAlpine (1)*) makes observation of the 191*7 poliomyelitis outbreak in 
England. Non-paralytic and paralytic cases are essentially the same as other 
series in the U. S. and England. He discusses in detail the diagnosis of 
polioencephalitis on the findings of nystagmus, photophobia and neck rigidity, 
during an epidemic in a patient who had been ill for a few days with head- 
ache and fever. He had several examples of a rare ocular disorder during 
the epidemic associated with emotional instability, tremor of the head and 
mild cerebellar seizures. 
Leslie and 1.'heeler (15) studied 202 cases of poliomyelitis admitted to the Childrens' Hospital in Columbus, Ohio, during 19U7• This group of 
cases included adults, as well as children. They found their patients did 
not differ markedly from the usual picture described for poliomyelitis. They 
felt that several features deserve emphasis: 1, A greater proportion of 
older patients suffered severe forms of the disease than was expected. 2. 
A history of contact was obtained in a significant number of cases, 3* Spinal 
paralysis occurring in association with bulbar involvement tends to affect 
the muscles of the neck, shoulder girdle and chest. U. One should not ex- 
clude the diagnosis if the cerebrospinal fluid contains less than 10 cells 
per cubic millimeter, 5. It is possible for significant new paralysis to 
develop after fever has subsided, 6. The respirator should be used early 
in cases of respiratory muscle weakness. 7. Tracheotomy should be used when 
it is clear an adequate airway cannot be maintained. 
Kelleher (16) has written a complete discussion of acute poliomyelitis, 
which attempts to give the average practitioner an insight into the clinical 
picture of the disease. The remarkable increase in poliomyelitis in England 
during 19li7 made the disease a problem for all doctors. The article is de- 
tailed in its consideration of the diagnosis of the various clinical types. 
Horstmann (17) makes a very complete presentation of the problems of 
the epidemiology of poliomyelitis. She traces the history of the disease 
from the ancients to the modern epidemics. The age incidence changes with 
the duration of epidemics as illustrated by Japan and the U. S. Early the 
disease is definitely infantile with a high paralytic rate. In recent U. S. 
epidemics there have been ever increasing numbers of abortive and non-paralytic 
cases. It has been suggested that the virus is so widespread in poorly sani- 
tated areas that infants are repeatedly exposed in life to subinfective doses 
and thereby acquire a lasting immunity. 
The infection of the U, S. soldier in the Philippines and in similar 
places suggests the conclusion that the distribution of cases was related 
to the susceptibility or xinmunity of the host. Owing to the prevalence of 
the virus, the native population had acquired a substantial immunity. In 
addition to the above, it is quite possible that there are strain differences 
in various parts of the world and that the immunity may be highly strain- 
specific, The virus is eliminated with greater frequency and for a longer 
times in stools than in material from the oropharynx. 
In animals (Chimpanzees) it has been shown that animals sacrificed during 
the carrier stage, the asymptomatic, may have severe, but scattered lesions 
throughout the central nervous system. These animals, though clinically well, 
excrete the virus in their stool. 
The diphasic course of the disease occurs in about $0% of cases. The 
virus probably enters the body by way of the mouth and pharynx and passes 
through the upper and lower intestinal tract within 2U-72 hours. It becomes 
implanted in certain sites, notably the pharynx and small intestinal wall, 
where it multiplies. It seems possible that any factor, physical or chemi- 
cal, may alter the metabolism of the cells of the central nervous system to 
upset the host-virus equilibrium and thus precipitate paralytic disease in 
persons, who might have remained healthy carriers. 
The facts indicate that fecal contamination of hands, food, etc., consti- 
tute the mechanism of spread rather than from the upper respiratory tract. Evidence points that flies are an accidental reservoir of the virus and 
not the important link in the change of events leading to epidemics. 
Strauss (18) traces the history of poliomyelitis in the U, S, and 
comments on the changing age incidence, 25-50$ of cases are over 5 years, 
whereas initially it was almost exclusively a disease of children under 5. 
In Japan, where the first epidemics are being experienced, the latter still 
holds, 
There is no evidence of any reservoir of poliomyelitis other than man. 
Water and milk have not been shown to spread poliomyelitis. Epidemics show 
a radial spread which is characteristic of person to person spread. It is 
difficult to show a connecting link because of the chain of as many as 100 
abortive cases between two paralytic cases. The virus is rarely present in 
the nasal secretions or saliva. 10-U0$ of the cases show it in the throat, 
however. It is present in 75-80$ of intimate contacts. The abundance and 
persistence of the virus in the stool suggests fecal rather than respiratory 
spread. 
Practical measures of control are difficult to apply. Isolation and 
quarantine are necessary, but cannot control an epidemic. Ideally, the pres- 
ence of the virus in the stool should determine quarantine but this is, of 
course, impossible. 
The question of closing schools, playgrounds, theaters, and swimming 
pools always arises. The author feels it is reasonable to close playgrounds 
and swimming pools. 
A plea for improved sanitation along railroads and canals (England) is 
made by Broadbent (19) to control poliomyelitis. He points out the high 
incidence of the disease along both these systems, which maintain only "prim- 
itive sanitation". 
A report by Nlssen (20) describes a poliomyelitis epidemic of 217 cases 
affecting the population of the Virgin Island, St. Helena. The epidemic 
began in Jamestown in November 19U5 and, after some delay, spread to out- 
lying districts. There was some evidence that the virus was introduced 
from South Africa, The incubation period of the first case was 31 days. 
The highest incidence occured in the age group 5 to 19 years. Two-thirds 
of the cases were abortive, 77 cases were paralyzed, and 11 (1U*3$) cases 
were fatal. 
Ryle (21) presents a study of an outbreak of poliomyelitis in an Eng- 
lish residential school of Ull pupils. Poliomyelitis occured in two houses 
of U8 and U3 boys. There were no cases in the rest of the school. The 
author was struck by the high incidence of minor illnesses in the "polio" 
houses, which was 31$ and 21$, respectively, as compared with an incidence 
of 6$ in the remainder of the school. The minor illnesses were colds and 
intestinal upsets. 
In a most comprehensive and complete discussion Aycock (22) gives ob- 
servations of the behavoir of poliomyelitis in warmer-climates. He finds 
the spread of the virus is a function of ordinary unavoidable and probably 
100 irreducible contact. Infection with the virus is preponderantly benign 
with paralysis occurring in only a small fraction of those exposed. In the 
tropics, widespread exposure, more frequently during the persistence of 
equally widespread maternal immunity, apparently results in a modified in- 
fection with resultant active immunity to be passed on to the offspring for 
repetition of the cycle. Thus, a high degree of commensalism has been 
reached. The mechanism through which a lower incidence of paralysis occurs 
in warmer climates seems to be the operation in nature of the principle of 
variolation rather than the principle of vaccination. 
According to Dauer (23) the incidence of poliomyelitis in the United 
States during the year 19U7 was less than for any year since 19U2, It was 
50% (15,000 cases) less than in 19U6, Only four states reported higher 
rates in 19U?-than in 19U6. The greatest number of cases were in heavily 
populated areas (Ohio, New York, California, Illinois, and Michigan), but 
the highest rates per 100,000 were in Idaho (72,1), Delaware (39.2), Rhode 
Island (18,9), and Nebraska (15,U). The case rate for the country was 7*U 
per 100,000 population. The largest area, where the disease was epidemic, 
included Southern Idaho, Eastern Oregon and Western Wyoming, In contrast 
to the U. S,, the incidence of poliomyelitis increased in 19U7 in the British 
Isles and Western Europe, 
An analysis of lOU patients admitted to a service for the treatment of 
early acute poliomyelitis is made by McAlpine et al (2U). In 5U cases, of 
which 2h were non-paralytic, a diagnosis of acute poliomyelitis was confirmed. 
No deaths occured. In nearly one-third of the proved cases, contact his- 
tories suggested the probability of an abortive attack of the disease in 
other members of the family or in friends. 
Current facts and theories and the history of poliomyelitis are given 
in detail by Meenan (25), He concludes there is no single portal of entry, 
but the area most often involved would seem unquestionably to oe the pharynx. 
The nerves most frequently involved are the trigeminal afferent system from 
the nose, mouth and pharynx and visceral afferent system of the ninth and 
tenth cranial nerves, serving in addition to the above the esophagus and 
bronchi, stomach and intestines. The seventh cranial and the sympathetic 
systems are also occasionally involved. 
In a summary and evaluation of present-day concepts of poliomyelitis, 
Freidewald (26) stresses the pathogenesis and diagnosis. He states the 
virus of poliomyelitis is found in the alimentary tract of a large propor- 
tion of the population during epidemic periods. In only a small percentage, 
however, does it invade the central nervous system. The diagnosis, which 
may be difficult in the abortive and non-paralytic types, is almost entire- 
ly dependent on the clinical manifestation and the spinal fluid findings. 
Francis, Brown and Penner (27) made a search for extra human sources 
of the poliomyelitis virus. The best evidence of the transmission of the 
virus supports a person to person transfer. This opinion has developed 
from evidence based on processes of elimination rather than by scientifical- 
ly proven experiments. Their attempts to isolate the virus from various 
extrahuman sources in epidemic areas have been made by inoculation of mon- 
keys and cotton rats and mice. Thirty-three wild mice, 112 wild rats, 3 
muskrats, k cats, 1 horse, many chickens, cows and hogs, and U3 pools of insects, representing 15,300 individual specimens were tested.. In addition, 
2h samples of sewage, 2 of sludge, 1 of soil and 3 of milk were examined. 
Of 38 pools of flies, one collection of 23 sarcophaga spp. from rural 
Tennessee (19U5) was shown to contain poliomyelitis virus. In all other 
attempts to isolate the virus, the results were negative. Virus from feces 
of a patient with poliomyelitis was actually taken up by flies and recovered 
by inoculation of rhesus monkeys. 
Studies by Rosenow (28) indicate that specific streptococci, isolated 
from patients, are able to produce flaccid paralysis and degeneration of 
anterior horn cells in mice. He further describes presence of pleomorphic 
diplococci in lesions of the spinal cord. Air samples taken in epidemic 
zones showed the presence of specific streptococcal precipitinogen and strep- 
tococcus able to reproduce symptoms in mice. Lower titre of antibody in the 
serum of convalescent paralytics than in non-paralytics suggests that per- 
haps paralysis occurs as a function of insufficient antibody formation. The 
study indicates that a specific type alpha streptococcus is, in some way, 
related to etiology in epidemic poliomyelitis. 
The theme of the article by Scobey (29) is that the implication of a 
virus as the etiological factor in, poliomyelitis is not beyond question. 
In evidence: both brain and spinal cord material from pollonyelitis patients 
and similar material from normal animals can produce paralysis when injected 
into experimental animals. The author gives further evidence to support his 
hypothesis that human poliomyelitis and related diseases result from poison- 
ing by cyanide contained in food and water, .and that the so-called virus of 
poliomyelitis is very probably a leukomain or an enzyme resulting from ac- 
celerated autolysis from such poisoning* Reference is made to the author's 
previous work in which he implicated the hydrocyanic acid, found in the 
free state or as cyanophore or mustard oil glucosides in vegetables, fruits 
and water, as the etiological factor in poliomyelitis. Also, it is pointed 
out that Collins and Collins and Marland, UO years ago demonstrated that 
poliomyelitis can be produced both in man and in experimental animals by 
cyanide. 
A preliminary report is made by Lepine (30) of a test utilizing an 
interference phenomenon resulting in the protection of mice inoculated with 
material suspected of containing the virus of poliomyelitis against a sub- 
sequent inoculation with the Lansing strain of virus. Five mice, h-6 weeks 
of age, were injected intracerebrally with extracts of the suspected mater- 
ial, The virus is extracted in the usual manner (P. Lepine, C. R. Soc, Biol., 
Paris, 19h9> 131, 573), Two days later, these five mice, in addition to 
five mice used as controls, are given an intracerebral injection with active 
Lansing mouse-adapted virus, with each mouse receiving about 50 The 
results drawn at the end of 10-11 days, showed k of the 5 controls aead or 
paralyzed and 3 of the 5 mice which were inoculated with suspected material 
were significantly protected. The materials used consisted of (a) cord 
material from monkeys inoculated with one standard laboratory strain and (b) 
fecal material collected from patients during the summer of 19U6 and pre- 
served in the frozen stage since that time. Extracts of normal human feces 
and cord material showed no protective action. 
Helwig (31) describes the poliomyelitis virus from a physical and 
chemical point of view, and gives information as to its reaction to various physical and chemical conditions. He outlines the culture methods, includ- 
ing the newer techniques employing human nervous tissue, chick embryo brains, 
etc. 
Methods of determining strain variability by immunological, neutrali- 
zation, reinoculation, and cross immunity studies, are discussed. Natural, 
active and passive immunity problems are considered, plus the difficulties 
and failures to produce effective artificial immunity. 
Experiments reported by Loring et al (32) show that complement-fixing 
antibodies can be demonstrated in the blood of rats immunized with formalized 
Lansing virus, in convalescent monkey serum, and in some convalescent human 
sera when concentrated Lansing virus from cotton rats is used as antigen. 
The experiments with the convalescent monkey and human sera provide 
definite proof that positive complement fixation can be demonstrated when 
concentrated Lansing virus prepared as described is used as the antigen. 
These latter results further support the importance of the Lansing virus or 
an antigenically related strain as the one responsible for the human disease. 
The results of this study by Wenner and Tanner (33) indicate neutrali- 
zing antibodies do appear following an attack of poliomyelitis, They may be 
present early in the clinical course of poliomyelitis, and they may not in- 
crease to an appreciable extent in the months following. On the other hand, 
the antibody titre may show a marked rise. The increase varies with the 
individual and probably with the severity of the disease. The neutralizing 
antibody in some patients does not reach a high level, but in some cases, 
there is considerable increase. Also, it seems clear there is no appreci- 
able drop in titre over the first year after illness. Apparently there is 
greater stimulation in paralytic than in abortive poliomyelitis. It appears 
that strains of poliomyelitis virus differ somewhat in antigenic mosaic, and 
this might explain differences in anti-body response. Individuals may have 
several abortive attacks of poliomyelitis, stimulating antibody production 
in varying degree. These antibodies, apparently, never reach high levels. 
McCarter (3U) reported the extent of the inflammatory lesions of 22 
cases of1 fatal acute poliomyelitis and showed the constant involvement of 
the central portions of the medulla, pons and midbrain with more or less in- 
volvement of the basal ganglia, thalamus and hypothalamies, The report 
showed no fatal cases to have occurred without some brain stem involvement, 
particularly the reticular formation of the medulla and contiguous struc- 
tures and that these lesions are among the earliest, if not the earliest, in 
the neuraxis, A variety of neural structures in the brain stem are involved 
which include the nuclei of motor and sensory nerves of both somatic and 
visceral function, and less well defined centers of vital function such as 
respiratory, cardiac, vasomotor and muscle tone inhibitory and facilitatory, 
The nerves so involved include the hypoglossal, abducens, trochlear, oculo- 
motor, motor nuclei of the fifth and seventh and the nucleus ambiguus and 
thus give the clinical manifestations of "bulbar polionyelitis", Also in- 
cluded are the great variety of symntoms which may stem from involvement of 
the general visceral afferent nuclei - dorsal motor nucleus of the vagus, 
nucleus salivatorius and occasionally the Edinger-Westphal nucleus. The respiratory center is within the area of severe involvement of the brain 
stem. In spite of its large margin of safety, the extent of irreversible and 
reversible lesions indicates that respiratory failure may be due to other 
causes than paralysis of the respiratory musculature* The problem of main- 
taining life in the acute cases is related to the interference with the 
poorly defined cardiac and vasomotor centers. The explanation of the dis- 
turbances of muscle tonus based on the spinal lesions has never been satis- 
factory but it can be better understood in view of the lesions in the reti- 
cular formation of the brain stem. 
Guyton (3£) in his article ’’Relation of Symptoms to the Pathological 
Physiology in Poliomyelitis”, emphasizes the fact that the virus of this 
disease attacks not only the anterior horn cells of the spinal cord but also 
the brain stem, the motor area of the cerebral cortex, and the sympathetic 
ganglia, as well as other areas of the spinal cord. Once the disease enters 
the central nervous system it spreads rapidly to all areas, giving symptoms 
related to the sites attacked. Encephalitis, meningitis, increased sym- 
pathetic central nervous system activity, urinary retention, and pain are 
common sequelae* Thus the lesions located in these widespread portions of 
the central nervous system cause a multitude of symptoms other than simply 
paralysis. Meningitic symptoms often herald the onset of the disease. Low 
back ache with occasional rigidity and neck pain is a common complaint, A 
spinal tap done during this period usually shows a moderate increase in 
white blood cells and protein. The spinal fluid pressure is usually slightly 
elevated. These meningitic symptoms are probably caused by irritation from 
the toxic products exuding through the pia mater from the areas of parenchy- 
matous inflammation. The virus of this disease can rarely be found in the 
cerebro-spinal fluid. The symptoms usually last two to three weeks. Encep- 
halitis may be quite severe and its time of onset varies with the site of the 
virus invasion. The encephalitic symptoms are due to the many midline lesions 
of the mesencephalon which often occur. There usually are no residual synp*- 
toms resulting from the encephalitis of poliomyelitis. Urinary retention 
is often the first symptom noticed in this disease and may precede paralysis 
for as long as two to three days, It is probably due to the involvement of 
secondary centers controlling bladder function which are located in the teg- 
mentum of the pons and the reticular substance of the medulla* Retention 
usually lasts for only a few weeks because this portion of the brain has great 
reparative powers. 
Symptoms arising from hyperactivity of the sympathetic nervous system 
may be both inhibitory and excitatory. The centers are located throughout 
the reticular substance of the medulla as well as other areas of the brain 
stem. The inhibitory centers are depressed to a greater extent leaving the 
patient with a hyperexcitable sympathetic system. As a result a rise in 
blood pressure and a fast pulse are common findings, The skin temperature 
is usually low particularly over the paralyzed portions of the body due to 
sympathetic vasoconstriction. Sweating is also a common complaint. Gastro- 
intestinal symptoms are often among the most severe results of acute polio- 
myelitis, The salivary secretion is scanty and viscid. Anorexia and con- 
stipation are also common. In some patients vomiting is a prominent feature. 
Severe muscular pain and muscular tenderness are invariable results of acute 
poliomyelitis. The cause of this pain and tenderness is as yet undetermined but it is possible if not probable that it is due to the hyperactivity of 
the sympathetic nervous system. The pronounced vasoconstriction might pro- 
duce severe muscle ischemia such as that seen in Buerger’s and Raynaud's 
diseases. Substantiating this contention is the fact that vasodilators ameli- 
orate the pain. Heat, prostigraine, curare, and paravertebral anesthetization 
all produce beneficial effects. It is probable that the tendency to muscle 
contracture is related to the ischemia. The rapid fatigue of recovered mus- 
cles however appears to be a permanent symptom and is probably due to recovery 
by a process of axonal branching, thus overloading individual nerves. 
Bodian (36) describes the course of poliomyelitis in the spinal cords 
of rhesus monkeys killed at intervals from the paralytic stage to the chronic 
stage. Included in the description are the cytopathological changes in motor 
nerve cells and more particularly in Nissl substance. Mitochondria and 
neurofibrils were found to be morphologically intact except in necrotic cells. 
It was found that axons degenerated between three and four days after cell 
destruction. Progressive stages of cell infection, destruction, and recovery 
are described. Paralytic animals show over 90% of all motomeurons are 
infected during the first few days, as is indicated by cytopathological chan- 
ges in the cell. Changes first appear in the Nissl substance and progress 
in orderly fashion until there is serious involvement of nuclear structure. 
Studies made during acute and recovery periods indicate that large proportions 
of motorneurons injured to the extent of severe loss of Nissl substance 
recover their normal appearance. The relation between damage and recovery 
of the motor nerve cell population to motor paralysis and recovery is con- 
sidered. 
Knapp (37) calls attention to the possibility of involvement of inter- 
nuncial cells in poliomyelitis. The function of these cells is not well known, 
except that they are concerned with the transmission of impulses from cell to 
cell within the central nervous system and are directly concerned with the 
correlation of motion. An explanation of the function of internuncial cells 
is as follows* The upper and lower motor neurons are connected by inter- 
nuncial cells in parallel, and destruction of part of this bridge might re- 
sult in muscle spasm in muscle which exhibits voluntary motor power. Also, 
it has been demonstrated that cats may have two neuron proprioceptive reflex 
arcs. If such a condition exists in man, it is possible ail internuncial 
neurons could be destroyed and the muscle would still retain the source of 
impulse for production of spasm. Coordinated muscular movement is controlled 
by the central nervous system, and the motor pattern is produced by the in- 
teraction of correlated neurons. Because there is never less than a three 
neuron chain between the cerebrum and the muscle, there is at least one 
internuncial cell involved in every motion. Thus, motor pattern is pro- 
duced by the interaction of correlated neurons. If anything happens to dis- 
turb any part of the pathway, the coordinated mechanism is upset. In polio- 
myelitis, such disturbances are evidenced by the spilling over of motor 
impulses into other muscles, which can be explained by the internuncial hypo- 
thesis. Recovery of affected muscles is explained as a training of new path- 
ways through intact internuncial cells in cases of incomplete destruction. 
Fcx and Madden (38) made a study of the sedimentation rate in acute 
poliomyelitis, using the Vfestergren method. Sedimentation rate determinations 
were carried out in a temperature controlled laboratory. Ranges of from 0 to 15 iran for males and 0 to 20 mm for females in the first hour were considered 
normal. In a series of 136 cases, only 22 (16.2$) showed an increase in 
sedimention rate. Of these, 16 were found to have concurrent infection ac- 
counting for the elevation. Thus, only 6 cases, or less than 5 per cent of 
the total, had an unexplained elevation of the sedimentation rate. The 
authors draw the conclusion that the sedimentation rate in uncomplicated 
poliomyelitis is quite constantly within the normal range, and that any ele- 
vation in poliomyelitis is highly suspicious of an improper diagnosis and 
the presence of a secondaiy infection. Also, this work suggests that there 
is no correlation between the white blood count, the spinal fluid cell count, 
and the sedimentation rate. 
Sedimentation rates (modification of Westergren technique) were done by 
Hartman and Weinstein (39) on the following subjects: (a) Sixty-five patients 
(21 adults and Ui± children) with poliomyelitis: (b) Forty-six patients with 
abnormal spinal fluids (22 suppurative meningitides, 19 viral and post- 
infectious encephalitides, 5 meningitides due to other causes); (c) Twenty- 
six patients (controls) who were thought to have clinical evidence of menin- 
geal irritation or central nervous system disease, but *o were found to have 
normal spinal fluids. Sedimentation rates were performed on patients with 
poliomyelitis at weekly intervals. The determination on patients with other 
types of central nervous system infections and on those patients suspected 
of having neurologic disease were performed usually only on admission since 
the purpose of the determination was to evaluate its early diagnostic sig- 
nificance. The conclusions drawn from this work are as follows: (1) Reli- 
ance on the sedimentation rate can be misleading in the differentiation of 
some cases of rheumatic fever and poliomyelitis. (2) In uncomplicated polio- 
nyelitis and other viral infections of the central nervous system, the ery- 
throcyte sedimentation rate is elevated in about jj0% of the cases at the 
beginning of the disease. (3) The sedimentation rate is unreliable in dif- 
ferentiating poliomyelitis from other infections of the central nervous sys- 
tem which simulate it. (U) No correlation could be established between the 
clinical type of poliomyelitis, the severity of the disease or the degree of 
abnormality of the spinal fluid, and the elevation of the sedimentation rate, 
(5) The differentiation of viral and bacterial neurologic infections cannot 
be made on the basis of the sedimentation rate value, (6) The erythrocyte 
sedimentation rate should never be used as a substitute for a diagnostic 
lumbar puncture. 
Pollack (UO) has written an article on the neurological signs of early 
poliomyelitis, The most important prodromal symptoms are lassitude, drowsi- 
ness, irritability and general tenderness of the whole body. Before paraly- 
sis occurs there may be twitching of single muscles or whole muscle groups. 
Pain is a constant symptom and involves one or more muscle groups. The pain 
is usually associated with hyperesthesia. The author contends that muscle 
spasm has been greatly over-emphasized in this disease. Eleven neurologists 
examined 32 muscle groups of every case of acute poliomyelitis admitted to 
the Chicago Municipal Contagious Hospital, at frequent intervals each day 
over a 30 day period. Spasm was interpreted as a sustained, reversible 
tetanic contraction. They found no instance of muscle spasm. Tenderness was 
present in less than 25$ of the cases, "Stretch pain” occurred in a few cases, 
particularly when paralysis was well established. Paralysis, contrary to 
the usual concept, does not appear suddenly and rapidly, but takes 3-5 days to reach its peak and is preceded by weakness. The latter fluctuates from 
hour to hour. 
Abt (Ul) presents an article which stresses the diagnosis of acute 
poliomyelitis and includes some notes on the history, incidence, epidemiol- 
ogy, and prevention of the disease. He quotes a recent article (Hayne, A, 
L,, Illinois M. J. 92: 16U*19U8), which enumerates the principal symptoms 
in 22U cases as follows: 
Fever 218 
Stiffness neck 1?2 
Headache 150 
Stiffness back 130 
Anorexia 101 
Vomiting 95 
Nausea 68 
Sore throat 5U 
Listlessness U6 
Urinary retention 3U 
Kehoe (U2) states that polionyelitis has replaced lues as the great 
imitator. In his classification of the disease he includes (1) healthy 
carrier (2) abortive type, (3) and (U) acute polionyelitis with and without 
paralysis, (5) bulbar type and (6) the encephalitic type. He calls atten- 
tion to the fact that the abortive type is frequently called "flu”, He 
concludes that there is no single pathognomonic element of history, symptoms, 
physical examinations or laboratory data that will give a positive diagnosis. 
Because of the bizarre symptoms presented by many cases of poliomyelitis, 
the problem of diagnosis is often considerable, according to Toland (U3)« 
Early symptoms of the disease may be: rhinitis, abdominal distress, nausea, 
vomiting and headache. The latter is probably the most reliable early sign, 
occurring in Sl% of cases studied by Pohl, Other suggestive symptoms are 
fever, stiff neck and back, painful extremities, and sore throat. Following 
initial symptoms, the disease may abate for 2h hours to 3 weeks, followed by 
paralysis or weakness of an extremity, often with pain and spasm of various 
muscle groups. Physical signs include absence or diminished reflexes in an 
extremity, muscle spasm, and usually no disturbance of sensoria. Bulbar 
poliomyelitis may be characterized by somnolence, respiratory difficulty, 
nasal phonation and facial weakness. 
Diseases most commonly misdiagnosed as poliomyelitis are as follows: 
(1) Encephalitides (many types). A history of recent diseases, such as 
measles, is important. These patients are usually more lethargic. This 
sign lasts longer than in poliomyelitis. They are weak with a definite early 
paralysis. Convulsions are more frequent. 
(2) Acute lymphocytic choriomeningitis. There may be central nervous 
system symptoms and transient sensory changes, which are not found in polio- 
myelitis. Course lasts only 7-lU days. Spinal fluid shows 2000 lymphocytes 
and the virus may be demonstrated, whereas, in poliomyelitis, count usually 
runs around 350 leukocytes, polymorphonuclear early and mononuclear late. 
(3) Tuberculous meningitis; This disease develops slower and produces 
a deep stupor, projectile vomiting and paralysis of extrinsic muscles of the 
eye. Spinal fluid may show tubercle bacilli and the chlorides are below 5o0 
mg,, whereas they are normal in poliomyelitis. Sugar is also lowered. (U) Acute rheumatic fever: The reason for misdiagnosis is most often 
due to poor history and physical examination. Here the patient may be mere- 
ly unwilling to move an extremity, whereas in poliomyelitis the patient is 
unable to do so. The sedimentation rate is elevated. 
(5) Meningismusj Usually concurrent with some acute infection, pre- 
senting stliT neck and back. They are often relieved of symptoms following 
partial spj.ua! drainage. This is not so in poliomyelitis. 
(6) Purulent meningitis; Has hyperactive reflexes, whereas polio- 
myelitis shows hypoactive reflexes. The spinal fluid is cloudy, shows in- 
creased pressure, grows meningococci on culture and contains elevated pro- 
tein and cellular content. 
(7) Syphilitic meningitis; History and serology are important; Patients 
may have optic neuritis, convulsions, nausea and extrinsic ocular paralyses. 
(8) Acute avitaminosis; Patients may not wish to move their legs be- 
cause of pain and there may be a protective muscular spasm. Reflexes and 
muscle power are normal. The x-ray findings are often diagnostic. 
(9) Intracranial lesions: Spinal tap, Queckenstadt test and x-ray may 
aid in the diagnosis, HemoXogic examination may reveal definite focal 
lesion. 
Other diseases less commonly mistaken for poliomyelitis have been; 
diphtheritic and arsenical neuritis, Guillain-Harre's syndrome, hysteria and 
trichinosis. 
Y'pitman's (hU) discussion of the differential diagnosis of poliomyelitis 
is very complete. He has drawn up a table of diseases to be considered in 
the pre-paralytic period. It includes choriomeningitis, encephalitis, lym- 
pho-granuloma venereum, acute purulent meningitis, tuberculosis, torula, 
typhus, etc.jj trichinosis and the common infectious disease of children. His 
differential diagnosis in the paralytic stage lists epidemic parotitis, 
periarteritis nodosa, Guillain-Barre syndrome, diphtheritic polyneuritis, 
acute porphyric neuritis, Landry's paralysis, botulism, tick paralysis, brain 
tumor, and hysteria. The urgency of poliomyelitis removes its differential 
diagnosis from the realm of an academic exercise. Its diagnosis must be con- 
sidered, formulated and delivered at the bedside. 
Fox et al (Id?) report a case of recurrent poliomyelitis with the first 
attack in August 19U5 and the second in August 19U6. Initial involvement 
was the musculature of neck, back, and calf, with no residual. The second 
episode involved chiefly neck, back, hamstrings, and bulbar signs, exclusive 
of respiratory mechanism. Again there was no residual, A review of the 
literature revealed 36 cases of recurrent poliomyelitis. These are presented 
in some detail. The period of time between the first and second episodes 
varied from one year to 29 years. The importance of understanding the dif- 
ference in these cases of recurrent attacks and relapses and recrudescences 
of the same episode is stressed. Previous investigations had set forth the 
argument that there must be at least two years between the first and second 
episodes. The present authors feel this length of time is excessive and that, 
as in the case presented, the time lapse may be shorter. It is stated that there is some immunity to the disease and this plays a role in the interval 
between first and second episodes. The belief that the second episode is 
caused by a different strain of the virus is set forth. 
Horn and Weidenthal (1*6) report a case of poliomyelitis in a 3 weeks 
old infant. They state that ordinarily the disease is rare in infants under 
6 months of age due to the supposed passive immunity they possess. Their 
case became irritable on the 17th day of life, developed fever, refused to 
swallow and became drowsy. There was no resoonse to penicillin and oxygen 
and death occurred four days later. The autopsy findings indicated meningo- 
polioencephalitis, This report mentions four other cases under 6 months of 
age in the English literature. 
Murray (1*7) asks for a review of terminology to assure uniform report- 
ing of cases of poliomyelitis. Kis proposed classification includes (1) 
non-paralytic poliomyelitis, clinical and sub-clinical, (2) paralytic polio- 
myelitis including (a) spinal, (b) bulbar, and (c) bulbar-spinal, and (3) 
polioencephalitis, 
A clinical report by Kobayashi and Kehoe (1*8) deals with the cases of 
poliomyelitis studied in the Iowa University Hospital from 192? through 
1937* After screening, 378 cases were finally studied. All of the 378 
cases were in the white race. Age distribution was rrom 0 to 15*9 plus. 
The mean age was 8.3 years. Highest incidence occurred between 1* and 5.9 
years. The peak incidence was in the month of August. Approximately 85$ 
had no known contact with a case of poliomyelitis, 28$ were the abortive 
type and 5U$ were purely the spinal type. The symptoms most commonly en- 
countered were presented and were those classically associated with the 
disease. The physical findings were those usually noted. An interesting 
finding was the W3C ranged from 2000 to 27,000, with 75$ less than 11,500» 
The mean leukocyte count in the cerebro-spinal fluid was 98, 80$ were 
round cells. The mean value for spinal fluid protein was 1*9. It was sig- 
nificantly higher in the bulbar forms of the disease. Treatment was the 
classic type, consisting of splinting, packs, and sedation, A few were 
given curare. The groups treated with Kenny packs were compared to those 
treated with other methods. The percentages of recovery closely approxi- 
mated each other for both methods. The mortality rate was 5.6$ (21 cases). 
Hullinghorst and Gifford (It9) considered 1?0 cases of poliomyelitis in 
pregnant women. They found the susceptibility to poliomyelitis was not 
affected by age, number of previous nregnancies or the stage of the preg- 
nancy. The bulbar type, which occurred in 23$ of the group, did not increase 
the tendency to abortion, premature birth or precipitate deliveiy. The 
maternal mortality was 19$ and the fetal mortality 26$. A third of the lat- 
ter were intra-uterine. Caesarian section is proposed when the death of the 
mother is imminent. While the disease may be transmitted to the newborn, 
there is no definite clinical, histological or virological evidence of trans- 
mission in utero. 
TREATMENT 
Gurewitsch, Hallock and Dugan (50) discuss the treatment of poliomyeli- 
tis in the acute and convalescent states from the physical therapy and the orthopedic aspect. Their aims are first to alleviate muscle pain, muscle 
shortening and limited flexibility, second, to develop optimal function of 
the weakened muscles, third, to rehabilitate the patient and make him as 
useful and independent as possible in the face of his handicap and fourth, 
to prevent the development of deformities in all stages of the disease. 
From the physical therapy standpoint, the method of choice since 19U3 has 
been daily baths at a temperature of 10U° Fahrenheit for 15 or 20 minutes 
repeated three to five times daily, depending on the severity of the symp- 
toms, Passive exercises to all joints are started from admission. The 
first aim of muscle re-education in poliomyelitis is the restoration of 
exact control of individual muscles. Muscle training is repeated several 
times a day. A daily performance of a muscle is the only guide to the opti- 
mal amount of effort to which it should be subjected. If there is no re- 
turn of power in four to six months, hope is given up. If muscles improve, 
exercises may be continued up to two years, Walking is encouraged by first 
placing patients on their feet in warm water up to the neck, which stimu- 
lates a multitude of postural reflexes without fatiguing muscles by weight- 
bearing, and then gradually reducing the level of the water. An attempt is 
then made to re-train muscles by functional occupational therapy. Psycho- 
logical aspects were previously neglected, so great attention is given to 
recovery, rehabilitation, vocational training, and, in the adult, job re- 
training-, Deformities are prevented by alleviating muscle pain and by pre- 
venting joints remaining for any length of time in a faulty position, and 
by opposing with mechanical means a deforming pull of imbalanced muscle. 
Proper position in bed is most important. Surgery is little needed since 
deformity can generally be controlled by treatment and with appropriate use 
of splints and braces. However, if deformity develops and does not yield 
to conservative measures, surgical correction is necessary. The above stud- 
ies are based on the study of 552 paralytic patients, who were treated from 
19U2 through 19U6 at the New York State .Hospital, West Haverstraw, New York. 
Cole (51) in discussing the present day treatment of acute poliomyelitis, 
feels the basic principle of treatment is the prevention of permanent and 
irremedial deformities. Under his regime, muscle spasm and shortening are 
treated by Kenny hot packs. He found prostigmine, curare, and sympathetic 
blocks to be unsatisfactory. Passive motion and stretching are begun as soon 
as pain ceases until a full range of motion of the joint is reached. This 
is followed by active muscle training and coordination. Loss of the pro- 
prioceptive reflexes is prevented by early standing and walking. 
Lewin (52) stresses the institution of therapy during the acute stage 
of poliomyelitis as soon as the diagnosis is made. Of primary importance 
is rest which should be complete and absolute with the involved muscles in 
a position of neutral pull. It should be continued until the acute stage 
is over. External heat is used in the form of packs and continued until 
symptomatic relief from pain and spasm is obtained. Gentle passive exercises 
are subsequently given. After the acute stage, the importance of physical 
therapy and muscle training to prevent and correct contractures is discussed. 
The use of braces hastens the return of function or gives stability to atro- 
phied parts. Surgical procedures are offered as means of overcoming defor- 
mities and contractures. The article includes a long list of directives which 
the author designates as "the Postulates of Polio” or "Poliograms". 
no: Bennett (53) outlines the treatment of poliomyelitis and recommends the 
following steps: 
(1) Early and accurate diagnosis. 
(2) Preparation of the patient for resumption of activity. 
(3) Coordinate and strengthen the existing neuromuscular units, 
(h) Increase the functional capacity of the patient. 
(5) Orthopedic surgery, if indicated. 
The results of treatment will be determined by the extent of central 
nervous system damage; and the caliber of medical care available; the 
general condition of the patient during the first three months; and the 
intelligence and responsibility of the patient and his parents. 
An excellent summary of present day therapy of poliomyelitis may be 
found in an article by Blattner (5L)* 
A regime for the treatment of acute poliomyelitis by Seddon (55) is 
quite standard in most respects. He gives no treatment to muscles that have 
remained paralyzed for U months. In addition he lists arguments for both 
early ambulation and prolonged rest in recumbency but gives no clear cut 
advantage to either. 
An article by Wilson (56) outlines the treatment of the severe compli- 
cations of bulbar poliomyelitis, Pharyngeal paralysis is treated with drain- 
age, aspiration and lastly, tracheotomy. Laryngeal paralysis is treated 
with tracheotony. When the respiratory centers are effected, treatment is of 
little avail. However, it is important to differentiate the former two from 
respiratory paralysis, since the pharyngeal and laryngeal paralysis may be 
aided. In summary, the treatment in severe bulbar poliomyelitis is palliative. 
* tracheotomy inhalator is described by Elam (57) for administering 
humidified oxygen, with the optional use of positive pressure and of modi- 
fications in respirator collar end headpiece to accomodate a tracheotony 
patient. The author distinguishes between (a) ventilatory deficiency with 
paralysis of the respiratory muscles, depression of respiratory center and 
obstruction of the upper airway and (b) alveolar deficiency with pulmonary 
edema, atelectasis and pneumonia. He recommends the respirator for (a)and 
oxygen for (b), An oximeter is used to follow the progress and to determine 
the need for a respirator and/or oxygen therapy. 
Graves (58) discusses the problems of caring for patients with acute 
poliomyelitis in the respirator. He shows the physical therapist is of great 
value in helping the Doctor by (1) muscle studies which help determine the 
extent of the infection, (2) treatment of muscles effected with packs, (3) 
re-education of muscles, even though the patient remains in the respirator, 
and (U) improvement of the patient's mental attitude by occupational therapy 
as well as physical therapy. It is stated that 70$ of the patients will 
require help while in the respirator in the acute stages of the disease. 
Ransohoff (59) holds that muscle spasm is responsible for most impaired 
function including dysphagia, respiratory embarrassment and deformities in 
poliomyelitis and that by the use of curare such spasms are relieved. The dosage of curare was 0.9 units per kg of body weight given every eight hours 
the first 2h hours, and then increased to 1.5 units per kg, given every 
eight hours intramuscularly. Administration of the drug was continued until 
spasm was relieved. The purpose of the above therapy is to allow stretching 
exercises and early ambulation, and thus reduce the incidence of contractures, 
Rive bulbar cases responded well to the above treatment. He further points 
out that many of the ’’good results” were attributed to the determination 
of the physiotherapist rather than to curare. The consensus was that more 
work and clinical study is necessary before the practice of early ambulation 
following the use of curare can be received as an approved method in the 
early treatment of acute poliomyelitis, 
In a report of 19 cases of acute poliomyelitis treated with ’’Intocostrin”, 
Rosenberg and Fischer (60) make the following conclusions; (l) Curare in 
closes of 0.9 units per Kilogram of body weight was of little value, (2) 
There was a very narrow margin of safety between the effective therapeutic 
dose and one which paralyzed the muscles of respiration or resulted in other 
toxic symptoms, (3) The addition of curare for periods of 3 to 10 days did 
not produce any more favorable results than those which had been obtained 
in previous years with hot packs and other forms of physical therapy. 
In a preliminary report (79 cases) on the use of procaine Hci, Priscol 
HC1 and diethylarainoethanol in the treatment of pain and spasm in the acute 
stage of poliomyelitis, Smith, Graubard et al (61) found the patients obtained 
complete relief within 2h hours with no deleterious side reactions. Occasional 
nausea and vomiting were present in the febrile stage. The rational of the 
use of the drugs is an interruption of the sympathetic reflex arc which 
supposedly perpetuates the pain and spasm during the acute phase. The 
dosage schedule was; (1) Procaine HCI, U0 mg. per Kg given intravenously 
as a 0.1$ solution in isotonic saline; (2) Rriscol Hci, intramuscularly and 
by mouth, given as follows; (a) Adults; 50 mg intramuscularly every U hours 
for U8 hours and subsequently the same dose orally, (b) Children, over 5 
years; 25 mg as above, (c) Children under 5 years: 10 mg as the elixir, 
with increases every U hours of 10 mg until flushing ensued, (3) Diethylamin- 
oethanol HCI, 1-2 gm daily by mouth in U divided doses. 
MacHamara (62) discusses the poliomyelitis problem in Australia, stress- 
ing the apathy of research workers of that country. He further outlines the 
history of serum therapy in the disease and questions the advisability of 
having given up this type of treatment. He feels many unsatisfactory results 
occurred because type ”H” polio cases were treated with type ”A” serum and 
vice versa. 
A series of twenty patients with acute poliomyelitis were treated by 
Rappaport (63) with thermal antibody, a substance prepared by autoclaving 
and oxidizing NaCl suspensions of streptococci isolated from patients with 
acute poliomyelitis. All twenty patients showed improvement within one to 
five days, especially in regard to swallowing and return of muscle function. 
The author felt the antibody had curative effects and returned patients to 
normal activity in a short period of time. A new compound ’’phenosulfazole” 
has been utilized experimentally in the treatment of poliomyelitis in mice. 
The results indicated that the mice could be cured if treated in the early 
stages, that a single dose prevented infection, and that surviving mice were 
immune thereafter. The drug acts on tissue cells, rather than on the virus. McCarroll (6U) has outlined the treatment of poliomyelitis in the 
recovery and residual stages. The first marks the end of the destructive 
process and begins when the temperature has finally subsided. It continues 
until maximum muscle recovery has been reached. It is invariably terminated 
within 16 months. From a practical point 6 months covers the significant 
improvement. The recovery phase is followed by the residual stage. Treat- 
ment during the first of these two stages is based on the underlying path- 
ology. When the acute stage is passed, the patient is left with the damage 
incurred by the motor columns as a result of the virus invasion. Attention 
is brought to the use of hot fomentations in 1903 by Kellogg and 1916 by 
Lovett, In evaluating three reported series using the Kenny treatment, the 
author finds ’’when viewed in the cold light of their own figures, one has 
difficulty accepting the Kenny treatment as the epoch-making contribution it 
is supposed to represent”. Prostigmine and curare have been tried, but ex- 
cept for possibly some relief of pain, they can have no direct effect on the 
course of the disease. No measures proposed to date give other than sympto- 
matic or supportive treatment for they are all directed toward the secondary 
manifestations and do not affect the amount of nerve cell damage. In dis- 
cussing comfort, the author indicates that all these patients are not writh- 
ing in pain and if allowed to lie quietly in bed, they are comfortable* 
The prevention of deformity is of utmost importance and position of 
function is maintained by hard bed, pillows, sand bags and splints. Exercises 
are begun under water through the range permitted by active motions. Passive 
motion is performed concurrently to maintain the full range of the joints. 
Ambulation is determined by the comfort of the patient. When weakness of a 
part requires it, braces will be necessary. During recent epidemics, the 
trend has been towards over-treatment and the over-expenditure of funds that 
should have been directed to scientific research. 
The residual stage requires highly specialized skill and entails cor- 
rection of deformities, arthrodesis for stability and improved function and 
muscle transplants to improve function and alleviate deforming forces. 
An article by Pohl (65) from the Elizabeth Kenny Institute lays claim 
to having prevented deformities in acute polionyelitis by treatment of the 
muscle spasm and shortening, which are accredited to direct attack of the 
polionyelitis virus on muscle and facia}, tissues. This article accepts the 
premise that the complications of polionyelitis are primarily due to this 
mechanism. It accepts the finding of central nervous system involvement, 
but minimizes this factor as a cause of deformity. The series of cases (1057) 
presented, of which 10hQ were discharged ’’free of gross deformities” contained 
395 ’’incipient deformities” at the height of the disease. These observations 
are the basis for the assertion that ’’the disease in the peripheral tissues 
rather than unbalanced pull of muscles causes deformity”. 
Litman and Bosma (66) studied the past growth of 133 children contract- 
ing polionyelitis in the 19h6 Minnesota epidemic. These were compared with 
siblings and classmates by use of the Vfetzel Guide for Evaluating Physical 
Fitness, The authors’ findings imply that, other things being equal, sus- 
ceptibility to polionyelitis is increased by conditions leading to unsatis- 
factory growth, that factors associated with poor growth predispose to polio- 
myelitis attack; that the disease is rare among children of stocky build; and 
that the disease is rare in the pre-pubertal stage of development. The basis for inequality in leg length in poliomyelitis is discussed 
in detail by Barr (6?) • The average skeletal age for cessation of longitudi- 
nal growth of the femur and tibia is lU-3/12 years in girls and 16-3/12 
years in boys* The causes of unequal growth and leg length are due to (1) 
local interference at the epiphyseal plate (congenital abnormalities, tumors, 
infections, trauma); (2) interference from remote causes (poliomyelitis; 
spastic, obstetric and traumatic nerve palsies; and disease such as caused 
by casting in tuberculosis and Legg-Perthes disease); and (3) factors stimu- 
lating unilateral growth (osteomyelitis, hemangioma, arteriovenous fistula, 
diaphyseal fracture). About 1/3 of the patients with poliomyelitis, treated 
as out-patients at the Massachusetts General Hospital, with onset before the 
age of 16, developed marked inequality in leg length. The factors effecting 
this result are age of onset, sex, and the amount and distribution of muscu- 
lar weakness in the legs. There is no shortening if the involvement is sym- 
metrical. The greatest shortening occurs in younger patients with one normal 
and one severely paralyzed leg, and is more severe in the male. 
To equalize length of legs in adults, a raised heel is used to correct 
discrepancies of 3/U to 1-1/2 inches; if more than 1-1/2 inches of shorten- 
ing is present, the sole must also be raised. Femoral lengthening was first 
tried in 1905, but the operation is formidable and complications frequent, 
especially loss of knee function. Tibial lengthening is now rarely done, 
because it has many dangers. Shortening of the normal limb can be done by 
femoral or tibial shortening* Equalization of leg length in the growing 
child has been attempted in several ways. Years of plaster cast immobili- 
zation should be avoided. The insertion of ivory pegs into or near the 
epiphyseal plates, and juxta-epiphyseal drilling are ineffective methods. 
Sympathectomy to stimulate growth has been done with promising results; it 
is not valuable after the age of 12 or 13, or if marked shortening has al- 
ready occured. Retardation of growth of the longer leg by operative arrest 
of growth of one or more epiphyseal plates has been accomplished, usually 
about the knee joint. Medial and lateral portions of the epiphyseal plates 
are excised and replaced by bony blocks. Deformities of the knee occurred 
in 5.6$ of one series of cases, and 11$ of another series. 10$ of one ser- 
ies required secondary operation. The operators claim success in 90$ of cases 
with this operation. Irradiation of the epiphysis holds definite promise. 
Barnes (68) has outlined the treatment he utilizes for all the phases 
of poliomyelitis, For the acute stage he recommends careful general medical 
care with adequate food and fluid intake. Physical therapy, consisting of 
movement of involved joints through the full range of motion, three times 
a day, and hot packs is begun. The hot packs he has found do not always 
give their reputed beneficial effects. For spasm he has used intravenous 
novocaine, 10 mgra per pound of body weight, once in 2U hours. Intensive 
physical therapy is given in the subacute stage with daily exercising of 
all muscle groups. Deformities are prevented or minimized by the use of 
braces. In the chronic stage, surgery is performed if necessary, after two 
years, or after maximum physical therapy has been achieved. He points out 
that braces as a rule are not designed to correct deformities, but merely 
prevent its occurrence or progression. 
Lowman (69) discusses the orthopedic surgeon and his co-workers, and 
here again, the author states that team work is most essential in the treatment of polionyelitis, Without it, the patient is inadequately treated 
and as a result will develop deformities which would be most difficult to 
correct. 
Wood (70) reviews the treatment of poliomyelitis from the orthopedist's 
point of view by dividing it into three stages. He states that the three 
aims of treatment are alleviation of pain and muscle spasm; prevention of 
contractures and deformities, and restoration of function as near normal as 
possible for that individual. The author reiterates the various physical 
therapeutic measures that are beneficial and the complications of the dis- 
ease that should be guarded against. 
Mustard (71) describes the orthopedic care during the convalescent 
stage of infantile paralysis. He states the Orthopedist must rely on the 
Neurologist, Psychologist, Physiatrist, Physiotherapist, Occupational Thera- 
pist, and Play Therapist, for aid in the successful management of this 
disease. 
An article by Ingersoll (72) presents an interesting group of cases in 
which the peroneus longus tendon has been transplanted for a paralyzed anter- 
ior tibial. The surgical technique is outlined. The operation in all cases 
now is performed only after a triple arthrodesis has been done. No trans- 
plant is performed unless the anterior tibial is completely paralyzed. The 
foot is always placed in slight valgus following operation. The convales- 
cence is shortened to three weeks. All operative procedures are followed 
by guided physiotherapy. 
Milgram (73) presents a discussion of the procedures necessitated by 
loss of deltoid, elbow flexors, and wrist extensors following poliomyelitis. 
To stabilize the shoulder, he recommends arthrodesis and resection of distal 
one-third of clavicle. A fibrous arthrodesis in the veiy young is accept- 
able followed later by bony fusion. The arthrodesis should never be done 
with the shoulder in external rotation. Palsied elbows he finds can be 
improved by the Steindler flexor-plasty operation, and for the loss of the 
wrist flexors he suggests arthrodesis. 
Cooksey (7U) discusses the role of Physical Therapy in the treatment of 
poliomyelitis• He emphasizes the importance of early and correct diagnosis 
stating that in a series of lOU cases studied by McAlpine et al Ul; were er- 
roneously diagnosed as poliomyelitis. He divides the treatment of polio- 
nyelitis into three stages. First, the inflammatory phase, in which the first 
consideration is saving the patient's life and in giving the patient proper 
rest. He advocates the use of hot wet packs, to be applied not more often 
than U times daily, and splints and a hard bed to rest muscles and joints 
in the neutral position. He moves the joints through a full range of motion 
once or at most twice daily to prevent contractures. He feels that by and 
large patients are over treated in the early stage and he definitely states 
that the hot packs as recommended by Kenny tend to interfere with the patient's 
rest. The second stage or stage of potential recovery, lasting from a few 
weeks to two years, is the phase in which Physical Therapy assists in the 
recovery of paralyzed or weak muscles within the limits determined by the 
permanent damage in the central nervous system. In this stage re-education 
exercises and re-establishment of coordination are of prime importance. The third stage is described as the stage of chronic disability, during which 
reconstructive surgery, appliances and vocational training are used to 
obtain maximum function of the individual. It is this third stage that 
maximum efforts on the part of all concerned is required. 
Kottke, Teigen et al (75) compared hot packs, curare and placebos in 
an effort to determine which if any was best as an adjunct to stretching of 
tight muscles affected with poliomyelitis. They concluded that objectively, 
no difference in the time required for a muscle to regain its normal resting 
length could be determined when using stretching alone, stretching plus 
curare, stretching plus hot packs or stretching plus placebos. They assumed 
first that stretching of unaffected muscles was necessary to restore normal 
resting length on polio muscles. On this assumption they found that the 
most important factor in determining return to normal length was whether or 
not the muscles were paralytic or non-paraly tic . Normal length was established 
in the non-paralytic muscles from 2 to U weeks whereas the paralytic group 
length was restored in a much longer time. 
Watkins (76) states that the major aim of treatment for the patient 
convalescing from poliomyelitis is the salvaging of all available neuro- 
muscular elements. He shows that the measures utilized are in the field of 
Physical Medicine, Recent research particularly electromyographic studies 
are quoted to show that a quantitative and scientific basis for the various 
modes of Physical Therapy are being established. He also briefly outlines 
the newer technics in field of treatment of poliomyelitis, chiefly, the use 
of progressive resistive exercise as described by De Lome for strengthening 
weakened muscles. 
DeLorme et al (77) show that the remaining innervated muscles following 
an attack of poliomyelitis respond to progressive resistive exercise by an 
increase in strength and work capacity in much the same manner as normal 
muscles. In studying a group of 2? affected quadriceps muscles in patients 
who had the disease 1 to U9 years prior to the study, it was found that 
strength and work capacity increased in all muscles put through progressive 
resistive exercise. 
NEUROMUSCULAR STUDIES 
Shaber et al (78) reporting on 20 patients describe the technic they 
developed in stimulation of poliomyelitis affected muscles by means of a 
special current generator. Daily, each muscle or muscle group was stimulated 
for a period of 10 minutes or until fatigue occurred. They determined that 
unless tension is secured in the paralyzed muscle, electrical stimulation is 
not effective. 
Huddleston and Golseth (79) by electromyograph studies on 330 paralyzed 
and paretic muscles in 20 cases of poliomyelitis determined that this type 
of study is of diagnostic and prognostic significance. The character of the 
various wave forms found in poliomyelitis affected muscles is described. 
Certain conclusions regarding diagnostic and prognostic findings are outlined. 
(Ed, note: This is an important paper in that it describes basic research 
in the relatively new field of electromyography. It is felt by many that the electromyograph will eventually be as important in the study of neuromuscular 
disorders as the electrocardiograph now is in the study of heart disease). 
Hodes (80) studying 22 patients in the convalescent stage of polio- 
rryelitis, determined electrical activity of paretic muscles before and after 
the "closed manual neurotripsy" method of Billig. No muscles studied had 
changed in power for at least one year. He found that muscles showing no 
electrical activity prior to neurotripsy continued to be electrically 
"silent" after neurotripsy. Muscles which were electrically active prior 
to neurotripsy produced potentials whose average amplitude was 22$ greater 
than their respective control values 8 months after neurotripsy. The 
neuromuscular block observed in the patients studied was either abolished or 
markedly reduced after operation (neurotripsy). 
By use of electromyography. Modes (81) determined that there is a linear 
correlation between conduction velocity of the fastest nerve fiber in the 
residual innervation of a polionyelitis weakened muscle and the maximal electro- 
nyogram obtained firom that muscle. He further determined that the degree of 
paralysis in a muscle affected by poliomyelitis could be estimated by compar- 
ing the electromyogram from that muscle with the electronyogram of a corres- 
ponding normal muscle. He postulates that there is a selective viral destruc- 
tion of motomeurons having axons of greatest diameter* BIBLIOGRAPHY 
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f 
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56, March, 19U8, SECTION 7 
NEUROMUSCULAR DISORDERS EXCLUSIVE OF POLIOMYELITIS 
Prepared by Donald W. lyddon, Lt. Colonel, MC., U.S.A. 
Physiology of Neuro-muscular Junctions 
Welsh (1) gave introductory remarks to a symposium on physiology of 
neuro-muscular junctions, in which he briefly sketched the evolution of 
mechanisms of communications between cells. Multi-cellular animals have 
need for coordination of activities of their many cells and organs. The 
primitive system of coelenterates with long processed sensory cells is des- 
cribed. The author briefly discusses cephalization and alignment of cell 
processes into nerves. Along with the development of the nervous system 
there was evolved the endocrine system. The endocrine system is a kind of 
"broadcasting" system in contrast to the nervous "telephone exchange". Of 
the chemical substance produced by the nervous system in invertebrates and 
apparently involved in junctional transmission acetyl choline is the best 
known. Acetyl choline and cholinesterase can be found in the nervous tis- 
sue of the flat worm. It can be shown in leeches that nerve to muscle im- 
pulse transmission is chiefly a chemical event while in arthropods it appears 
to be electrical. The question arises - are there two strictly independent 
modes of junctional transmission - chemical and electrical - or are chemi- 
cal and electrical events interwoven, with one or the other more easily de- 
monstrable at the particular junction being investigated. 
Kuffler (2) discusses the "transmitter" problem, i.e., events that take 
place between the arrival of a nerve impulse at junctions and the subsequent 
setting up of a muscle impulse. The following sequence is presented to 
explain "transmitter":- nerve impulse - transmitter - end plate potentials - 
muscle impulse. The author discusses some of the characteristics of the end- 
plate which has become a physiological entity. Duration and intensity of 
the "transmitter" is analyzed. The current theory of acetylcholine trans- 
mission is briefly discussed. Experiments on current flow in the terminal 
nerve region on the transjunctional region are presented. Potential changes 
were recorded from end-plate regions of isolated preparations while stimuli 
were applied within 0.5 mm. to the nerve nearby. Sub-threshold depolariza- 
tion of the nerve terminals by applied currents or by blocked nerve impulses 
did not affect appreciably the end-plate membrane. Neuromuscular delay 
periods are discussed relative to current spread from nerve to muscle. 
The author concludes that; 
(1) Action currents in the terminals are not effective in polariz- 
ing the end-plate region. 
(2) The "transmitter" action occurs during the breakdown in the 
terminals. The breakdown period is too short to account for 
the analyzed "transmitter" duration. Prolonged polarization in the terminals does not prolong the transjunctional 
potentials. It is believed that during the "breakdown" 
in the nerve terminals the ions that are liberated could 
account for the observed phenomena. 
The author cites a communication from Dr. Eccles which states that the 
electrical hypothesis cannot be reconciled with recent work. Eccles and his 
co-workers favor acetylcholines as the sole mechanism in neuromuscular 
transmission. 
Muscle Relaxants 
Edwards (3) states that muscle relaxant drugs have great possibilities 
in clinical practice. The ideal muscle relaxant is defined as one easy to 
administer, having the effect directly proportional to the dose, reversible 
in action and having no side-effects of any kind. The pharmacological action 
of the dextro-tubo-curarine and allied compounds is described. The pharma- 
cological action of myanesin is mentioned. As an aid to diagnosis, curari- 
form drugs have been found of considerable value. In myasthenia gravis as 
little as one-fortieth of the normal dose will elicit an exaggerated effect, 
even to respiratory failure. Curarisation has been found useful in the 
differential diagnosis of painful muscle spasm, especially in backache. If 
the pain is due to spasm it is instantly relieved by curarisation while 
pain due to root irritation is unaffected. As an adjuvant to anaesthesia 
curare is recognized as invaluable. In shock therapy of psychotic states 
curarisation before the convulsions does much to prevent the bony and soft 
tissue injuries. Muscle ruptures are less likely to occur since the violent 
contractions are prevented. Curarisation in the acute phase of polionyelitis 
has been used to relieve the tightening of the antagonistic and synergistic 
muscles and thereby allow the affected part to be held in the optimum posi- 
tion. The best therapeutic results have been reported in convulsive states. 
Both tubocurarine and myanesin have been used. It has been used in idiopa- 
thic epilepsy, tetanus. Parkinsonism, cerebral palsy and traumatic, arthritic 
or postural muscle spasm. The possibilities of further employment of muscle 
relaxant drugs are discussed. 
Berger and Schwartz (U) report on oral myanesin in treatment of spastic 
and hyperkinetic disorders. Because of the properties of "nyanesin" to re- 
lax spasticity and rigidity, its action to restore deranged reciprocal in- 
nervation and its inhibiting effect on certain release symptoms, suggested 
that the drug might be useful in the treatment of certain spastic disorders. 
Other investigators using this drug obtained short lived beneficial effects 
with intravenous use of the drug. Certain undesirable side effects such as 
thrombophlebitis and hemoglobinuria were observed. The purpose of this re- 
port is to draw attention to the fact that "myanesin" is well absorbed after 
oral administration and to outline briefly the satisfying results obtainable 
in previously intractable conditions. The drug was administered as a 3.3 
percent solution in 20 percent aqueous propylene glycol with syrup of cherry 
20 percent. 
Hemiplegic patients showed a striking recovery of some of the voluntary 
movements of the paralyzed limbs ten to twenty minutes following administra- 
tion. Remarkable results were also obtained in certain cases of cerebral 
diplegia. The drug appeared effective in spastic, athetoid, and choreiform types of the disease. The favorable effect of myanesin in diplegia is 
due to the depressent action on the nuclei of the brain stem and to its 
power to reestablish disturbed reciprocal innervation* Myanesin also 
proved effective in various conditions causing muscular spasm such as 
subacromial bursitis, low back pain, and osteoarthritis of the hip joint* 
Patients receiving the drug should be watched closely since the chronic 
effects of the drug on human beings is still unknown. Generally speaking 
the principal use of nyanesin remains.that of abdominal surgery* 
Mallinson (£) describes the mode of administration of myanesin for 
different age groups and different surgical procedures. Aside from surgery, 
myanesin has been used medically for spastic conditions and tetanus. It 
has been suggested that myanesin causes increased bleeding. The author 
does not substantiate this finding nor was he able to show increase in 
hemolysis. There is no question in the mind of the author of the effi- 
ciency of myanesin as a muscle relaxant under light anesthesia. The dan- 
gers of curare and nyanesin are compared and it is concluded that hazards 
of curare are greater than those of nyanesin* 
In correspondence to the editor Gottlieb (6) reports a case of para- 
lysis agitans of four years duration treated by injection of d-tubocurarine 
chloride in oil. When reaction to the drug was favorable (usually on 30 
mg.) the clinical picture of relaxation to a drunken state for two hours 
occurred* Gradually generalized weakness developed and lasted for two 
days. At the end of this time her strength gradually returned and her 
walking improved to the state of being unassisted for the first time in 
four years. There was however, no change in her tremors. The improve- 
ment lasted two to seven days. Comparison is made of this experience to 
those of Drs* Clark and Hotston. The author was impressed with the appar- 
ent unstableness of the drug* 
Recent reports indicated that curare might offer valuable aid in the 
amelioration of spastic paraplegia and paraparesis* Thirty four patients 
on the Paraplegia Service of the Cushing Veterans Administration Hospital 
were selected as spastic problems by Kuhn and Bickers (?)• The group was 
divided into two groups of seventeen each, and an attempt made to distri- 
bute them evenly according to level of lesion and severity of spasm* One 
group received intramuscular injection of 1?£ mg. of d-tubocurarine chloride 
in oil and white wax every forty-eight hours for 10 doses; the other group 
of seventeen were given an equal volume of physiological saline solution 
intramuscularly throughout the same period. The observers and patients 
were intentionally kept unaware of patient distribution during the study* 
The observers were not able to estimate correctly the patients receiving 
d-tubocurarine* Of the total of thirty-four, 16 were judged incorrectly. 
No beneficial effects relating to the relief of spasms in paraplegic or 
paraparetic patients were obtained by intramuscular injection of d-tubocura- 
rine in oil and white wax. The role played by suggestibility in therapy 
of this type of patient was clearly demonstrated* 
Cooper and Hoen (8) administered curare in the form of intocostrin 
to 8 patients with marked spasticity resulting from spinal cord injuries. 
In doses that produced side effects necessitating discontinuance of the 
drug, no appreciable lessening of the muscle spasticity was noted. Into- 
costrin was noted to have no effect on the hypertonic urinary bladder* Schlesinger (9) reports on pharmacological agents in the treatment 
of neuromascular disorders. Cerebral palsy is frequently seen in cripp- 
ling degrees which are refractory to physical therapy. Attempts at 
exercise will often increase the degree of severity of this abnormal 
state. The advantage of drug therapy is in its ability to ameliorate 
these mechanisms and allow purposeful therapy. Curare has interesting 
potentialities in the treatment of spasticity. The drug brings about 
a blocking effect at the nyoneural junction. By maintaining certain 
concentrations of curare it is possible to create a differential block 
and, in effect, filter the abnormal volleys of nerve impulses. Tubo- 
curarine in wax and peanut oil seems useful in maintaining low blood 
levels over long periods of time. An attempt is made to saturate the 
patient with curare at levels that do not interfere with voluntary func- 
tion but do reduce the hyperactivity of the stretch reflex. Thus the 
voluntary power is unmasked and retraining is made possible in order to 
rebuild muscle volume and useful habit patterns* 
Other drugs that have possibilities in this field are diparcol, 
myanesin, and parpanid. Diparcol is useful in true rigidity bub its 
value in the mechanisms seen in cerebral palsy is not yet clear* Myanesin, 
a brain stem and spinal cord depressant, is efficient in reducing spasti- 
city, rigidity, and involuntary movement. Parpanid is of interest in the 
treatment of rigidity and tremor of the Parkinson state* The authors 
state that in their hands, prostigmin has been of no value. Certain axioms 
are pointed out. 
1. Drugs will only ameliorate abnormal mechanisms. They will not 
restore normal habit patterns. 
2. Drug therapy is more useful in the younger age group. 
3. Drug therapy should make the outlook of the physical therapist 
more optimistic and her task less formidable. 
A British Firm has produced a synthetic paralysant acting like curare- 
nyanesin. Musgrove (10) reports the use of this drug in 200 cases. In 
most of these cases, abdominal relaxation was an essential surgical re- 
quirement. Dosages and techniques of administration are described. In 
this series of cases myanesin proved to be a very good muscle relaxant. 
When given in adequate dosage it compared favorably with curare. Myanesin 
produces less respiratory depression. 
Peripheral Nerve Injuries 
In a nerve trunk, which is the unit with which the clinician deals, 
there are many different fibers and their resistance to trauma varies 
so that resultant syndromes are innumerable. Roaf (11) divides nerve 
injuries into four classes: 
(1) Complete section - solution of continuity and separation of 
the proximal and distal portions to such a degree that spontan- 
eous recovery cannot occur. (2) Partial section# 
(3) Transient lesions - the nerve has suffered temporary "concussion11 
and can recover spontaneously. 
(k) The nerve is being subjected to continuous compression which, if 
left untreated, will inhibit recovery and may ultimately lead to 
section# MNeural compression” is suggested as a convenient short 
name for this syndrome# 
If all causes of continued compression have been removed; if there 
are no important complicating factors, such as ischemia and sepsis; if the 
peripheral end-organs are in good condition; and, if the patient is coop- 
erating in his own re-education, a nerve which shows no recovery after 
three or four months has probably been divided (completely or partially) 
and requires surgical intervention# 
Pollack (12) reports on the Peripheral Nerve Registry, established 
during World War II, in the Office of the Surgeon General of the Arny, 
which permitted follovt-up studies on peripheral nerve lesions# The prob- 
lems posed to the Subcommittee on Neurosurgery of the National Research 
Council at the beginning of the War concerned the causes of nerve injury, 
the prevention and treatment of infection; the methods of joining severed 
nerves, including bridging gaps; the use of various types of sutures and 
glue; the effect of delay in suturing; studies of the effects of nerve 
injury, paralysis, anesthesia, atrophy, contractures, ulcerations, and 
sweating; studies of the microscopic appearance of nerves and muscles to 
learn the effect of infection, of various types of treatment, and of 
operations; development of methods of treatment of wasted muscles and con- 
tractures; studies of the effect of treatment by drugs, vitamins, and so 
forth; and improvement of old methods and development of new ones for 
ascertaining when a nerve was torn apart or was growing satisfactorily# 
Some of these problems were solved but several remain unanswered. 
Compression and Severance of Nerves*Varying degrees of compression 
produce a characteristic form of paralysis dependent on the force of com- 
pression and length of time exerted. The effects range from temporary 
motor paralysis with rapid recovery to early paralysis and gross defect 
in sensation. It was shown that under such conditions, in the peripheral 
portion of the nerve, there was no disappearance of fibers but only loss 
of myelin sheath. Because the nerve remains connected, no muscle wasting 
occurred* 
Results of Nerve Injuries, After sensation is lost, adjacent nerves 
at the borders of sensory loss grow into the anesthetic areas, and re- 
covery of sensation may occur# After nerve severance the muscle atrophy 
that occurs has been known to be associated with fibrillation. It was 
proved that fibrillation is not the cause of atrophy# In cases of nerve 
injury, sweating ceases and the electrical resistance of the skin becomes 
increased, 3y means of an ohmmeter these areas of sweat loss can be 
outlined# 
Electrodiagnosis, Investigations were unsuccessful in devising 
methods to differentiate between injuries by compression or concussion 
and those associated with severance of the nerve. A number of devices for stimulation and measurement were invented and many 
important observations were made on conduction and conduction velocity* 
Treatment* It is the consensus of opinion in this country that the 
earlier an injury to a nerve is repaired, the better is the opportunity 
for good recovery. Studies were made on suture material, glue, various 
tubes, and cables of fibers. Further evidence is required regarding 
the value of nerve grafts in human cases* 
Microscopic Evidence of Regeneration* When, at operation, a gap be- 
tween the severed nerve ends is found, there is, if sufficient time elapse 
has occurred, evidence of some regeneration in the distal segment* It is 
the opinion of most investigators that the new fibers in the distal seg- 
ment find their way from the proximal segment* There still exists differ- 
ences of opinion, however, on this so called "spontaneous regeneration" 
of the distal segment* 
Seddon (13) gives a review of work on peripheral nerve injuries in 
Great Britain during World ’War II* 
Classification of Nerve Injuriess- 
1. Neurotmesis - In this condition the nerve is completely disorgan- 
ized, although it may appear to be in continuity. All essential 
elements are interrupted and there is complete degeneration distal 
to the lesions. In lesions in which the nerve may be blocked by 
interneural scar tissue, the only effective treatment is resec- 
tion and suture. 
2. Axonotmesis - The axons and their sheaths are completely interrupted, 
but the internal architecture of the nerve is preserved, in partic- 
ular the endoneural tubes. There is complete peripheral degenera- 
tion which is spontaneous, and the quality of recovery is very 
good since the outgrowing fibers remain in the tubes to which they 
belong. Restoration may be confidently expected. 
3. Neurapraxla - The axons remain in continuity, but the myelin 
sheaths, especially those of the larger fibers, are interrupted. 
There is dissociation paralysis but no reaction of denervation in 
the affected muscles. Recovery is rapid and complete. 
The major difficulty is to distinguish neurotmesis and axonotmesis 
since the clinical picture is identical. Neurotmesis occurs in open wounds 
and it is desirable to explore all nerve lesions, due to open wounds as 
soon as possible after wound healing. Closed nerve injury as in fractures 
are found to be axonotmesis in k out of cases. It is here justified to 
delay exploration until it is determined that spontaneous regeneration 
is overdue* 
In estimates of rate of nerve regeneration, for practical purposes, 
it is safe to expect an overall rate of 1mm a day* Comparison of primary nerve suture with early secondary suture 
indicates that the delayed operation is preferable. If a secondary 
operation is done in three or four weeks after injury, the extent of 
intraneural damage is easily detected on reaction of the nerve ends. 
After a delay the sheath hypertrophies and will hold sutures well. 
Nothing should be done to the nerve, aside from bringing the ends to- 
gether at the time when the primary suture of the skin is performed. 
It is possible to close gaps up to 17 cm by mobilization of the nerve 
stumps and suture with joints in acute flexion. In general flexion 
of knee or elbow beyond a right angle is unjustifiable. Homogenous 
grafts have been uniformly unsuccessful. At present the only hope lies 
in autogenous grafts which have their limitations. There is a significant 
fall in the proportion of good results where the delay between injury and 
repair was greater than six months. There was also a smaller proportion 
of satisfactory recoveries where the length of resection exceeded 5 cm. 
(Ed. note: It is the consensus of opinion in the United States that the 
earlier an injury to a nerve is repaired, the better is the opportunity 
for recovery.) 
Meyerding (Hi) reports two cases of traumatic sciatic paralysis com- 
plicating fractures of the acetabulum with posterior dislocation of the 
hip. This type of injury occurs when the patient is thrown against a 
car dashboard in the sitting position. The fracture fragments may cause 
immediate nerve damage or there may be nerve damage due to the hematoma 
or callus. With evidence of traumatic neuritis, immediate surgical inter- 
vention is recommended to prevent irreparable nerve damage. When treat- 
ment is delayed the scar tissue makes reduction of the dislocation very 
difficult, furthermore, surgical treatment may fail to relieve the nerve 
injury. 
Riesenman (1$) presents two case histories as examples of mechanical 
or pressure neuritis - one of sciatic neuritis secondary to abnormal 
posture and the second case, a median nerve "pressure neuritis” 
tional11 or "dental neuritis"). Mechanically induced neuritides make up 
a large percentage of the etiologic types of neuritis seen by the clini- 
cian. The nerves most often involved are the radial, ulnar, median, 
sciatic and peroneal. The author discusses the various specific causes 
of pressure neuritis under the main headings of occupational, recreational, 
or postural. The therapeutic regime should consist of measures directed 
toward the alleviation of symptoms. The symptoms consist of sensory, 
motor, and trophic factors appearing singly or in combination. Success- 
ful treatment takes into account certain principles which can be laid 
down for practical guidance: 
1# Removal of the determining factor when known and amenable* 
2. Provision of rest for the affected part* 
3* Maintenance of neuromascular nutrition as far as possible by 
warmth, massage, and electric modalities. 
Prevention of deformities and other sequelae due to contractures, 
adhesions, fibrous growth, arthritic change, and trophic change, 
generally* 
130 The importance of a detailed history referable to the circumstances 
under which the palsy develops is stressed in order to arrive at a diag- 
nosis of "pressure neuritis". 
Diddle (16) reports a case of paralysis of the serratus anterior 
muscle in a parturient. This case is that of a 23 year old white primi- 
para seen four months post partum. Pain in the right shoulder, fatigue 
and weakness of the right arm had begun 2k hours after normal delivery. 
Pulling straps had been employed during delivery. Whenever the right 
arm was hyperextended or abducted, the scapula rotated outward. The patient 
received diathermy and massage over a six weeks period along with 10 mg. 
betalin twice daily. The pain, weakness and deformity gradually disappeared 
and muscular strength returned to normal. The author discusses briefly the 
history of the disease and the several methods of treatment which have been 
advocated. Since the end results obtained by operative measures are not 
always satisfactoiy it is recommended that conservatism be practiced. 
According to Bailey, (17) to justify a diagnosis of neuritis there 
must be a loss of function, either motor or sensory. The term "neuritis" 
is used rather loosely by the profession. Neuritis may be caused by a 
variety of injuries, many of which are preventable. The author presents 
8 cases of neuritis to show the importance of pressure as a cause of neuri- 
tis. Treatment consists of rest during the acute phase, splints to prevent 
contractures, and galvanic stimulation to prevent atrophy. Active exercises 
should be started as soon as movement begins. 
Cerebral Palsy 
Collis (18) emphasized that the child with cerebral palsy is not 
essentially a deformed or mentally retarded child. The important thing 
is to begin treatment before deformity or mental deprivation have occurred. 
In cerebral palsy one of the control centers in the brain is damaged - 
if this is the cortex, the result is spasticity; if the basal ganglia, 
the result is athetosis; if cerebellum, the result is ataxia; extensive 
damage is likely to result in rigidity and tremor together. Where one 
part only is damaged the treatment aims at "by-passing" the damaged control 
center in order to produce a more normal child. An attempt is made to 
teach a different cerebral control of musculature from that which is nor- 
mally controlled by the damaged section of the brain. 
Phelps and St. James (19) discuss the prevention of postural deformi- 
ties in children with cerebral palsy. Because of its complexity it should 
not be expected that one drug, one type of brace, certain surgical proce- 
dures or a routine set of exercises can result in a spectacular response 
in cerebral palsy. Cerebral palsy includes five primary classifications - 
spasticity, athetosis, ataxia, tremor and rigidity. Under these five 
classifications are several sub-classifications. Cerebral palsy may be 
defined simply as a lack of motor control, but one must recognize the 
multiple variances in order to realize that one or two principles of treat- 
ment cannot be suited to every situation. Since certain types are prone to deformity it is essential that an 
accurate diagnosis is made and preventive measures instituted early. 
The spastic type is most prone to deformity because of muscle imbalance. 
The patients -with rigidity are next most susceptible to deformity due 
to lack of contractility of muscles with fixed posture. The tension 
type athetoids are apt to acquire deformity as a result of prolonged 
postural attitudes plus the tension which favors certain muscle groups. 
Patients with tremor show little or no tendency to deformity. Those 
with ataxia demonstrate relaxed ligaments and hypermobility most notice- 
able on weight bearing. 
After diagnosis is established, an accurate muscle analysis should 
be made to determine any imbalance about a joint. Braces for cerebral 
palsy differ from those in poliomyelitis since, in the latter, the prob- 
lem is one of weakness. Stronger braces are needed in cerebral palsy to 
overcome muscle strength. In planning bracing it is necessary to con- 
sider all factors involved and, if necessary, err in bracing too exten- 
sively rather than insufficiently. Bracing for the upper extremity is not 
usually so extensive as for the lower extremities. The braces should be 
checked frequently to see that they fit properly. A program that will 
encourage good postural habits over extended periods is essential. A 
carry-over to night braces assures good preventive measures against de- 
formity. 
Surgery, in cerebral palsy, has a definite place, but is limited 
in scope. Athetoid conditions are contraindications for surgery in most 
cases because of the athetoid shift. Careful and accurate evaluation is 
necessary before surgical procedures are done. 
Certain drugs are used in selected cases of cerebral palsy. These 
drugs axe chiefly the relaxant types. Prostigmine has its most beneficial 
effect in rigidities and tension athetosis. Curare is a paralytic drug 
which must be employed with discretion and under close supervision. 
Many cerebral palsy children present serious feeding problems be- 
cause of their difficulties with chewing and swallowing. Because of the 
tremendous exhaustion of energy in the athetoid type increased food in- 
take is necessary. Spastic children being more sedentary require less 
than the average diet. 
It has become clearly apparent to those working with cerebral 
palsy that specialized forms of physical therapy offer the best means 
of treatment for the child with cerebral palsy. Surgery offers limited 
possibilities in special selected cases. Drugs have value only as ad- 
juncts to physical therapy. The physical therapy measures used in cerebral 
palsy are entirely different from those involved in disease or injury to 
the spinal cord and its roots. The problems of cerebral palsy include 
paralysis, spasticity, rigidity, ataxia, tremor and incoordination, with 
multiple combinations. There are also speech, hearing, visual understand- 
ing and mental defects which further complicate the picture. The meaning and value of postural reflexes, reactions of defense, 
tonic neck reflexes and pattern movements, which are all vital consider- 
ations in the majority of patients suffering from cerebral palsy, should 
be familiar at least in their clinical aspects* Fay (20) describes the 
various defense reflexes that may occur and the development of pattern 
movements. In the past, these basic reflexes of automatism have been 
considered an undesirable problem that plagued the therapist as well as 
the physician-in-charge* Organization of these reflexes and utilizing 
them for purposes of developing muscles, relaxing antagonists and coordina- 
ting tone have resulted in definite improvement* These reflexes have been 
made to fit into pattern movements with great improvement in spasticity. 
Many pattern movements originating in the lower motor levels of the 
mid-brain, the medulla and the upper cervical and thoracic portions of the 
cord offer a challenge to the therapist to determine whether it is possi- 
ble that certain automatic spinal reflexes can be organized and coordinated 
with what remains in the higher cortical centers and bring about pattern 
movements• 
Position is a point of extreme importance* If the patient is lying 
flat on his back there will be increased tone in all the extensor groups 
that are being treated when attempts are made to produce flexion* If the 
patient is turned on the abdomen, an immediate reverse of tone effect 
(through the labyrinth) may be accomplished and a great deal of muscle 
spasticity will be diminished. Automatic reflexes latent in man may be 
utilized again in spastic paralysis at primitive levels of function to 
the benefit of the patient, and as an aid to the rehabilitation if properly 
augmented and trained. 
The first requisite of braces in cerebral palsy according to Knight 
(21) is that the braces must be strong in order to resist the constant 
scissors deformities and to withstand the stresses of the athetoid and 
spastic. The cosmetic appearance of braces cannot be considered in 
cerebral palsy since functioning of the brace is of primary importance. 
The second requisite of the brace is to have joints which will work 
freely with the constant side thrusts and torsion* It is the author's 
experience that ball bearing type joints are best. In the athetoid the 
brace is used to control the deforming tendencies and to aid in training 
a pattern of motion. The brace of the spastic serves to maintain the 
extremity in good weight bearing position and to prevent the deformity 
thrusts. The braces should always be calipered so that the shoes can be 
put on in a knee flexed position and the brace later attached to the 
shoe. This method of application insures that the heels are well down 
in the shoes. 
In treating cerebral palsy cases the policy is to defer surgery at 
least until the growth is complete. Braces are then a very important part 
of therapy. 
Grayson (22) offers a method of testing for handedness. This paper 
does not attempt to go into the question of dominance with the various 
aspects that enter into the problem in cerebral palsy cases, but simply to point out a few basic facts with which every therapist testing these cases 
should be familiar. Handedness testing cannot be successfully carried out 
on a child under two years of age, and it can be made with more certainty 
after the age of three. Both arms are treated and trained during the baby- 
hood period unless there is a definite spastic hemiplegia. 
Considerable study has been done on eyedness and its importance in 
relationship to handedness. In the majority of cases the dominant eye is 
on the same side as the dominant hand. Simple tests for determining eyed- 
ness are described. A test form for handedness testing is presented. In 
preference testing for handedness the therapist is cautioned to stand 
directly in front of the child and pass or place the testing material in 
the center position. Both the child*s hands should be free to receive the 
object. The preference testing should be done 10 to 15 minutes daily for 
a period of a month and results should be tabulated* Various testing mat- 
erials are listed. 
Myasthenia Gravis 
Although a somewhat rare disease, according to Viets (23), myasthenia 
gravis is not so rare as was believed ten years ago. There are probably 
1500 cases in this country. There is only one sympton of myasthenia gravis - 
an exaggeration of normal fatigue of voluntary muscles. Up to 1935 the 
mortality rate varied between £0 and 75 percent - indeed a flgrave myasthenia” 
At the present time the mortality rate is probably less than 10 percent. 
There is always fatigue of the voluntary muscles, but early in the 
course of this disease certain muscles are more easily fatigued than others. 
The muscles that have to do with the eye and eyelid movements are most 
frequently affected. In U5 percent of the cases the first symptoms often 
are ptosis or diplopia. The second most important group are those with 
general weakness, fatigue in walking upstairs, difficulty in raising the 
arms and doing ordinary tasks. Another group, about 20 percent, have dys- 
phagia and dysarthria. The age distribution of patients varies from the 
earliest years in life to well into the eighties. The patients most fre- 
quently seen are young adults or people in middle life. Prostigmine, now 
as neostigmine, has proven to be the drug that has the most marked thera- 
peutic effect and the one that is used as a diagnostic test. Neostigmine 
treatment iMtaHk is a form of substitution therapy. There is a chemical 
dysfunction at the junction of the nerve and muscle; neostigimine is added 
to this myoneural junction and the chemical reaction is restored to normal, 
or partially so. 
It has been observed at autopsy that the thymus gland was changed in 
some patients dying of myasthenia gravis. This observation has led to 
treatment by surgical removal of the thymus. The author is of the opinion 
that the results are just as good with neostigimine therapy. It is doubt- 
ful as yet whether thymectomy, which is still experimental, is of value 
in this disease or not. Thymectomy is to be advised in patients who have 
not done well under medical treatment. Myasthenia is seen occasionally in adults, uncommonly in adolescents, 
and rarely in infants and young children. Bowman (2U) presents case 
histories of three children, ages 3-7/12, U-6/12, and 8-2/12 years, with 
myasthenia gravis who had been treated during the last three years at 
Boston Childrens Hospital. Photographs of the patients taken before and 
after the "prostigmin test” are shown. The authors summarize by stating 
that all infants and children having ptosis of the eyelids should be given 
the "prostigimin test". Myasthenic symptoms and signs were evident at 
birth in Case 1, and this is the first case of congenital myasthenia gravis 
to be recognized in the medical literature. 
Bell and Perrin (25) report a case of a woman, aged 31, who developed 
myasthenia gravis/ Symptoms were first noticeable during the seventh 
month of pregnancy. She developed weakness of the muscles of chewing and 
swallowing and also of her arms. There was marked ptosis of the eyelids. 
The patient was treated with prostigmine but her condition became pro- 
gressively worse. Three months after onset of symptoms a diagnosis of a 
tumor of the thymus gland was made. The tumor was removed and the patient 
then showed a steady improvement and could be maintained on prostigimine 
15 mgs. t.i.d. 
The following points vie re raade;- 
1. The condition is frequently associated with Grave*s disease. 
2. These patients sometimes die suddenly with respiratory paraly- 
sis therefore they should carry a syringe and ampule of prostig- 
mine for emergency. 
3. The sensitive muscle group for diagnosis is that of the swallow- 
ing muscle. 
ii. The mode of action of prostigmine is to inhibit cholinesterase, 
thus permitting the normal function of acetyl-choline at the 
nerve synapse. 
Surgical treatment of the thymus gland is the treatment of 
choice in advanced cases who are regressing even on large doses 
of prostigmine. 
Troncelliti (26) reports a case of myasthenia gravis occurring in a 
9 year old boy."' The author states that he can find only 37 cases in the 
literature occurring under 1? years of age. The chief complaint in this 
case was bilateral ptosis of eyelids. There was a diplopia in the infer- 
ior field of vision. One year prior to admission there had been diffi- 
culty in breathing. The remainder of the physical and neurological 
examination was negative except for slight posterior cervical adenitis. 
The ptosis was more marked in the evening. On 0.3 gm of quinine sulfate 
extreme fatigue resulted so that the patient was too tired to count to 100. 
On 1 mg of prostigmine methyl sulfate the ptosis disappeared as did the 
tired sleepy feeling. The child's treatment was standardized on 15 mg 
of prostigmine bromide four times daily, and 8 mg of ephedrine sulfate 
twice daily. The total duration of the disease in this case at the time 
reported was 17 months. Although myasthenia gravis is an unusual disease, the diagnosis 
can often easily be made because the patient presents a rather typical 
picture. The physiological disturbance seems to be at the myoneural 
junction. The outstanding features of the disease are the rapid fatig- 
ability of the muscles on activity and the quick restitution of function 
on rest. Ptosis, diplopia, dysarthria, dysphagia, along with general 
weakness are the presenting complaints. The diagnosis is based on the 
clinical picture plus the results of a test dose of prostigmine. 
(Prostigmine methyl sulfate 1.5 mgm. and atropine sulfate 0.6 mgra. and 
dramatic recovery of strength results within 20 minute.) Maintenance 
doses up to a total of 180 mgm. per day may be given but 15-30 mgm. 
every 3-U hours is usually sufficient 
Meredith (2?) gives two case reports in detail. Case number one 
is that of a UU year old railroad conductor whose disease was controlled 
on prostigmine bromide 37*5 nigra and atrophine sulphate O.i+5 mgm every 
3-2 hours while awake. Case two is that of a 1+2 year old negro laborer 
who was controlled on 30 mgm. of prostigmine bromide and 0.1+5 mgm of 
atrophine sulfate every two hours during the day, and one dose at mid- 
night. In addition he was given 1+3 mgm. of ephedrine sulfate four times 
daily. 
The subject of pregnancy in myasthenia gravis has received little 
attention in the literature and only a small number of cases have been 
reported. Harris and Schneider (28) review the literature and report a 
case of pregnancy in myasthenia gravis. The effects of pregnancy upon 
myasthenia gravis are discussed. A discussion of labor, puerperium, 
mortality, and infants bom of myasthenic mothers is presented. In the 
one year post-partum follow-up of this case presented, there has been no 
improvement in the myasthenia gravis, but rather a slow downward progress- 
ion. There was no decrease in the amount of prostigmine needed after 
delivery, in fact, dosage was gradually increased over the one year period 
so that the patient was taking between twenty-five and thirty 15 mg. 
tablets daily. The patient had been maintained on 90 mg. daily for the 
five years before pregnancy. 
Eaton (29) gives a warning concerning the use of curare in convulsive 
shock therapy of patients with psychiatric disorders who may have myasthenia 
gravis. The value of convulsive therapy has become widely established in 
the treatment of psychiatric disorders, particularly the depressions. Fur- 
thermore, curarization preliminary to convulsive therapy is widely used. 
Bennett and Gash (30) found that the weakness of patients with myas- 
thenia graviFwas greatly intensified,by small amounts of curare, one 
tenth to one twentieth the usual dose will result in marked exacerbation 
of symptoms of a patient with myasthenia gravis. It is to be emphasized 
that quinine and curare diagnostic tests should not be used in patients who 
are seriously weakened, since further weakening may result in death. The 
ordinary curarization of a depressed patient, preliminary shock therapy 
might prove fatal should the patient also suffer from myasthenia gravis. Myasthenia gravis is not nearly so rare as it was once assumed to be and 
it must be ruled out in any case in which curarization is to be used 
preliminary to shock therapy if tragedy is to be avoided. 
Causalgia 
Although certain aspects of causalgia have been described previously, 
it remained for Mitchell and associates (31) to describe the condition# 
The essential features were repeatedly confirmed with the passage of time. 
In certain details, however, variations were encountered. 
Shumacker, Speigel and Upjohn (32) discuss the signs and symptoms 
and particularly the vasomotor status in a group of 90 cases studied by 
them. The upper extremity was affected in i*9 cases and the lower in Ul» 
The series contains no cases of complete paralysis in which widely divid- 
ed and completely separated ends of the nerves were demonstrated at 
operation. Concerning the onset of pain the data is unreliable since 
in many cures the memory for such details during the first few hours or 
days of injury was hazy. Fifty patients said pain began immediately 
after injury; 23 from the first to the eighth day; 9 during the second 
or third week; 3 from one to two months; and one U months after injury. 
Four cases no data. All except four described '’burning” as part of the 
characteristic of the pain. Forty cases described ’’burning” pain only. 
Almost without exception the pain was made more intense by the use of the 
part, and by touching or tapping the affected hand or foot. The pain was 
localized in the hand or foot in all instances; in a few it also extended 
up the forearm or leg. 
In all cases an effort was made to evaluate carefully the vasomotor 
status. It was not always possible to perform all the circulatory tests 
desired; often the patients fear of aggravation of pain could not be suf- 
ficiently overcome to obtain his permission or cooperation. Twelve patients 
said the injured hand or foot was warmer than the contralateral one. Twenty- 
seven said the hand or foot was colder than the other. The other £l patients 
thought there was no difference in temperature or that the involved ex- 
tremity was sometimes warmer and sometimes colder. Thirty patients showed 
the affected extremity to be oinker than its mate. The hand or foot was 
cyanotic in 29 cases and pallor was noted in 5 instances. The peripheral 
pulses were not significantly altered except in cases of major artery 
injury, ligation, or thrombosis. Examination of data recorded reveals 
that in only a few instances was the skin temperature in the range of 
maximal vasodilatation. In nearly every case a distinct increase in 
warmth occurred after sympathectomy. Atrophy and contractions tended to 
be more severe in cases with arterial occlusion. 
Most of the observations made by Mitchell, Moorehouse and Keen con- 
cerning the signs and symptoms of causalgia have been substantiated in 
the reported studies. In 86 of 90 cases, burning pain was present. The 
transient partial relief of pain from wetting the part was not commonly 
observed. Mitchell, Moorehouse and Keen originally found causalgia only 
in cases of partial nerve injury. It has subsequently become apparent 
that causalgia may occur when the nerve damage is apparently cornplete. The glossy fingers, tapering, cur/lng of the nails which occurred so com- 
monly in the original account was present in only a small percentage of 
this series. Such changes were more frequent in impaired vascular supply. 
It would seem that the physiopathological explanation of the pain of 
causalgia must take into account the fact that the pain may occur in the 
presence of increased, decreased, or relatively normal vasomotor tonus, 
as well as the fact that altering the vascular tone by any means other 
than by sympathetic interruption results in no effect upon the pain in 
the majority of cases. In a survey of recently reported experiences with 
over 300 cases of causalgia, no true case of causalgia has failed to re- 
spond to sympathetic block by a period of complete or nearly complete 
subsidence of pain. 
The origin of pain and the pathways for its conduction remain an 
ill understood feature of neurophysiology. The causalgic state presents 
a challenging field in such studies. According to Threadgill (33) the 
essential lesion in this condition appears to be one of vascular and 
neural irritation resulting from wounds involving blood vessels or nerves. 
A pathway of certain afferent impulses from the injured peripheral 
nerve to the cord by way of the sympathetic paravertebral structures will 
explain many of the bizarre findings of others reported in this paper and 
the effects of sympathectomy in relieving pain when vasospasm is not a 
factor. Reference is made to previous experiments by the author which 
showed that in unilaterally sympathectomized animals, when the posterior 
roots of the lumbosacral plexus were cut bilaterally, painful sensations 
were perceived by the animal only in the side where the sympathetic gang- 
lia, trunk, and rami were intact. It was, therefore, deduced that pain- 
ful stimuli were conducted via the grey communicating rami to the sympa- 
thetic ganglia. To explain the mechanism of causalgia, it is proposed 
that general visceral afferency is a functional component of the spinal 
nerve and that this pathway reaches conscious levels under certain condi- 
tions. 
For some time it has been evident that interruption of the sympathetic 
pathways constitutes the most reliable, conservative, and safe method of 
treatment of causalgia. The recent war experiences which have been re- 
ported are in agreement concerning the general efficacy of sympathetic 
interruption. 
Shumacker, Speigel, and Upjohn (3i*) made a study based upon obser- 
vations on 90 patients who were thought clinically to be suffering from 
raajbr causalgia. Most of the patients were studied at U.S, Army General 
Hospitals, Sympathetic ganglionectomy for the lower extremities was 
accomplished through an anterior extraperitoneal approach under spinal 
anesthesia. The upper extremities were denervated by the posterior pre- 
ganglionic operation of Smithwick, performed under intratrachial anesthe- 
sia, Fifty-seven patients were treated by permanent sympathetic interrup- 
tion, Twenty-one responded well to single or repeated procaine sympa- 
thetic blocks. One hundred sympathetic blocks were performed 
in 83 patients. Seven patients in the series received no sympathetic 
anesthesia because sympathectomy was felt advisable because of poor circu- 
lation or extensive nerve damage. In a few, relief of pain was incomplete. In some of these the burning pain was relieved completely and the residual 
discomfort was that of tingling or aching. In the other instances the entire 
pain was dramatically relieved. The duration of relief varied. Seventy- 
eight blocks were followed by relief of pain for two hours or more, 'When 
each successive block resulted in a shorter period of relief, no permanent 
alleviation was achieved by further injections. On the contrary, those patients 
who were eventually rendered free of pain by procaine blocks generally noted 
progressively longer periods of freedom from pain following each successive 
injection. Of the 83 patients in whom sympathetic anesthesia was induced one 
time or more, 21 obtained permanent relief. Ten required only one injection. 
Thirty-four patients were treated by permanent interruption of the sym- 
pathetic pathways in the upper extremities. Thirty-three by operation and 
one by alcoholic infiltration. The duration of pain at the time of operation 
ranged from 1,7 to 13 months, an average of U.7 months. In 25 patients the 
pain was completely relieved and in six others the residual discomfort was 
inconsequential. All patients were followed for several months after opera- 
tion and none had return of pain. 
Twenty-three patients were treated by lumbar sympathectic ganglionectomy. 
The duration of pain at the time of operation varied from 3 weeks to lU months, 
an average of 5.28 months. Relief of pain was complete in 11 patients and in 
another k patients an excellent result was obtained, the residual discomfort 
being trivial. 
Of the 57 patients treated by operation (or alcohol injection) an excel- 
lent result was obtained in U6, or 81$, Detailed case reports are presented 
in the patients whose operative results were only good, fair, or poor. 
This s tudy confirms the concept that interruption of the sympathetic 
pathways constitutes the most reliable and safe method of treatment of 
causalgia. 
In those cases in which there was incomplete relief of pain, several 
considerations must be taken into account. Four cases recorded obtained 
relief after excision of the first lumbar ganglion after incomplete relief 
following excision of 2nd and 3rd ganglia. Two cases obtained relief on 
reoperation to excise the 12th or 11th thoracic ganglia after having had 
excision of the lumbar chain. 
Shumacker (35) makes an attempt to clarify the clinical picture and the 
treatment of causalgia, Causalgia was originally described by the following 
features: pain of varying intensity and predominantly burning in character, 
coming on some time after incomplete injury to a peripheral nerve, felt 
chiefly in the periphery of the extremity, exacerbated by touching the part, 
dependency, jarring, emotional excitement, dryness, and generally by heat, 
relieved somewhat by wetness and cold, associated usually with glossy, red, 
blotched skin, always comparatively increased in warmth, and leading in many 
instances to emotional instability. In certain details, further experience 
has revealed aberrations in the original accounts. The condition is prone to 
occur after injury to the median or sciatic nerve. In a total of UOO cases 
the upper extremity was affected in 238 or 60$ of cases. Mitchell, Moorehouse and Keen (31) were not of the opinion that the 
causalgia was immediate. Approximately 50$ of the cases in the authors' 
experience stated that the pain was immediate, however, it is admitted that 
the patient's memoiy for details after such experiences may be inaccurate. 
Though burning is the usual and characteristic type of pain, there are 
reports of series of cases varying from h»h% to hS% of patients that did not 
have burning. 
It is concluded that wet applications are by no means always effective 
in providing partial relief. Though warmth often helps those with vasocon- 
striction, and cold those with vasodilation, there are many exceptions. The 
pain is always felt most intensely in the periphery of the extremity and the 
pain is exaggerated by touching, noises, hunger and excitement. 
The original belief that glossy skin is especially common in causalgia 
and that such changes never occurred in the absence of burning has not been 
supported by other studies. About one-third of the author's patients presented 
evidence of relatively normal vascular tonus. Most of the others had rela- 
tive vasodilation though some had distinct vasoconstriction. 
The essential diagnostic criteria of causalgia appear to be the presence 
of constant spontaneous pain following partial or, more rarely, complete 
injury to peripheral nerves, generally, but not always, predominantly burn- 
ing in nature, exacerbated by certain stimuli, and capable of temporary, 
complete, or nearly complete alleviation during sympathectic procaine anes- 
thesia. 
It is only within the past few years that results of large series of 
cases treated by sympathectomy are available for analysis. In a review of 
reported cases excellent results were obtained in 76.3$, good results in 2V%, 
poor results in 2.7$. Excellent results are 82,9$ in upper extremity and 65.6$ 
in lower extremities. It is felt that the available data suggests that at 
least a small number of the incomplete cures or failures following sympathec- 
tomy are explainable on the basis of inadequate sympathetic denervation. 
There is general agreement concerning the efficiency of sympathectony in the 
treatment of causalgia. There is, however, considerable disagreement concern- 
ing the usefulness of procaine blocks as a therapeutic measure. The author 
is convinced that certain individuals can be treated satisfactorily by blocks 
alone. If successive blocks give relief for the same or diminishing periods, 
one should abandon these measures and proceed with operation. 
Syrrtpathectony should be done early, in causalgia, in order to prevent 
long continued suffering, to avoid narcotics and addiction, and to prevent 
damage to the affected extremity. 
No theory, as yet offered, furnishes an entirely satisfactory explana- 
tion of pain of causalgia. The two most widely accepted theories are those 
of Livingston (36) and Doupe, Cullen and Chance (37). The author briefly 
reviews several theories of the mechanism of causalgic pain and concludes that 
none of the current theories is entirely satisfactory and that further inten- 
sive study is required. 
iuo; The picture of causalgia is briefly described in its typical aspects 
by Gordon (38). In exceptional cases causalgia is observed without neuritis, 
A case is presented as an illustration of the existence of causalgia over 
the area of distribution of one single nerve, without trace of motor or 
objective sensory manifestation referable to that nerve, A forty year old 
woman, without history of trauma, developed, about two years ago, burning 
pain over the distribution of the ulnar nerve at the wrist and hand. The 
burning pain appeared in paroxysms many times daily. The hand temperature 
was variable during the paroxysms. There was no evidence of atrophy. Pres- 
sure on the main nerve trunk did not provoke neuritic pain. The result of 
treatment of this case is not discussed. The author places this case on 
record because of the absence of neuritic symptoms and lack of traumatic 
etiology. The modes of treatment procedures that have been employed in this 
disease are listed by the author. 
Echlin (39) reports his observations on major and minor causalgia on a 
study of 1500 cases of peripheral nerve injury. It is concluded that major 
causalgia resulting from war wounds of large peripheral nerves is more common 
than has been reported. Pain is the central feature of causalgia; the vaso- 
motor and trophic changes are variable and non-specific. The classical syn- 
drome of causalgia is seen in its complete form only when the condition is 
at its height. The majority of patients with major causalgia showed a grad- 
ual spontaneous improvement so that as this improvement takes place, all 
gradations of intensity in the condition may be seen. During this period of 
improvement a case that at one time would have been classified as severe 
causalgia later might be termed a minor causalgia. On the other hand, some 
patients may present the picture of minor causalgia without passing through 
a phase of major causalgia. Realization of these minor forms is important 
since the condition is probably more common than is generally recognized. 
Regardless of the intensity, the same abnormal mechanisms are apparently 
operative. Even though gradual improvement may take place over a long period 
of time, the irreversible changes that take place in the tissues and the emo- 
tional disturbances of the patient dictate that the condition be treated early. 
Sympathectomy should be effected in severe causalgia if a sympathetic block 
has given temporary relief and, under such conditions, brings about cure to 
the majority of patients. 
Tourney (hO) reported on 31 patients with reflex sympathetic dystrophy, 
treated by sympathectomy, who were seen at the Lahey Clinic from July 19Uh, 
to July 19U7. Reflex sympathetic dystrophy is a disturbance of the sympathe- 
tic nervous system, characterized by pain and sympathetic phenomena which 
may follow major or minor traumata. The most prominent feature of reflex 
sympathetic dystrophy is chronic continuous burning pain. Characteristic 
sympathetic phenomena also appear, most commonly vasoconstriction but there 
may be vasodilatation. Objective signs which indicate the syndrome are cold- 
ness, sweating, skin-color changes and swelling of the extremity. X-ray of 
the bones show spotty decalcification. 
There has been an enormous confusion of terms for this syndrome. Terms 
referring to this syndrome are "post traumatic ascending neuralgia", "reflex 
sympathetic dystrophy", "causalgia", "minor causalgia", "post traumatic 
pain", "traumatic sciatica", "Sudecks atrophy". The pain may come on direct- 
ly after injury and never abate, or it may commence weeks or even months after the injury has occurred. In all thirty-one cases reviewed the condition 
was severe enough to require sympathectony • The author could not find any 
typical chain of circumstances which produce reflex dystrophy. It is the 
author’s belief that spontaneous lessening causalgic pain is the exception 
rather than the rule. The agonizing pain of causalgia fills the patient's 
entire life and consciousness and brings about serious personality changes. 
The local injection of procaine to block the sympathetic ganglia is the key 
to diagnosis and may also effect a cure. The general statement may be made 
that patients who obtain little or no relief from a block will obtain little 
or no relief from sympathectomy; the reverse is true to a lesser degree. 
The results in this series were? good to excellent in twenty cases, 
fair in two cases and poor in nine cases. In every case the coldness, blue- 
ness and increased sweating were relieved by sympathectoiqy. Results in sym- 
pathectomy are better in younger age groups. The average time lapse between 
injury and sympathectomy was thirty-two months. Fifty-five percent of the 
females and seventy percent of the males had good to excellent results. It 
seemed that in cases of longer history of symptoms and well worn pathways, 
the patients did not respond so well as those whose symptoms were of shorter 
duration. The importance of active use of the extremity, as a valuable means 
of breaking the reflex, must not be forgotten. Furthermore, it must be 
emphasized that sympathectomy is not a cure-all for dystrophies. At present, 
sympathectomy is by far the best operative procedure for the treatment of 
reflex sympathetic dystrophy. 
The underlying principle in prevention is to treat the trauma so that 
painless function of the extremity is restored in the quickest possible time. 
The author believes that the modem tendency to use procaine locally in the 
treatments of sprains is an excellent one, and that its use should be widened. 
Overtreatment of fractures is dangerous; splinting should not be continued 
too long and function of the extremity must be encouraged. Of this series, 
fractures and sprains were the inciting causes in one half of the cases. 
Surgery, such as orthopedic, of painful joints may be required, together with 
sympathectomy, to effect a cure. 
Cullen (Ul) reports on a study of twenty-four patients in whom the major 
symptom was persistent pain after injuiy to one or more peripheral nerves. 
In a publication of the Medical Research Council (1920) the pain of causalgia 
was described as being: Spontaneous in onset; hot and burning in character; 
intense, diffuse, persistent, and subject to exacerbation; excited by stimu- 
lation which did not necessarily produce physical effect on the limb; usually 
aggravated by emotional excitement which brought on a paroxysm; and respon- 
sible for profound changes in the emotional state of the patient. Basing 
his opinion cn this series of cases it is the authors belief that these de- 
scriptions appear to be much too rigid. Blocking the sympathetic ganglia 
with novocaine often gives valuable information despite the fact that the 
test is largely subjective. The technique of sympathetic block for upper and 
lower limb pain is described. 
The objective findings encountered are glossy skin, spindle fingers, and 
clawed stained nails. Macerated skin and bullous lesions are sometimes en- 
countered but may be related to reluctance to allow cleaning. Hyperhydros is 
is not constant. Vascular dilatation is not always present. The limb tempera- 
ture varied through coldness to normal to increased. Bone changes were not specific. In regards to psychical assessment the author feels that too much 
attention has formerly been paid to personality changes. They are the result 
of pain. Once the pain is relieved they disappear. Every case of severe 
causalgia calls urgently for treatment, not only to relieve pain and suffer- 
ing, but also to prevent crippling deformities, especially in the hand, which 
results from voluntary immobilization. In this series neurolysis was per- 
formed on nine occasions and in every case slight relief was obtained for a 
short period, (maximal period 3 weeks). Periarterial sympathectomy was done 
on five occasions without permanent benefit. 
Of eleven cases treated by radio-therapy, four subsequently required 
sympathectomy. Of the other seven patients, six were convinced that improve- 
ment began two or three weeks after treatment and was progressive. The re- 
maining patient was not improved and has since had a tractotomy. Three pa- 
tients who obtained relief had brachial plexus traction lesions. This is a 
point of considerable importance, since in this group relief by sympathetic 
block is by no means the rule. Sympathectomy was performed on eight patients. 
Pain was completely relieved in seven. One patient continued with burning 
pain in the ring finger but the rest of the hand was free of pain. Twenty- 
three novocaine injections were performed in seventeen patients. Of these, 
eight later had sympathectomy and nine were treated by radio-therapy. No 
permanent relief from novocaine was observed. The patients who had no spec- 
ific therapy showed, with a passage of time, varying degrees of improvement. 
While not altogether free of pain, they are not seriously incapacitated. 
Olsen and Maycock (U2) give a brief history of the studies 0$ causalgia 
and report a case, rHe pain is usually a constant, persistent, deep burning 
pain, experienced exactly or roughly over the cutaneous distribution of a 
mixed or sensory peripheral nerve. One must beware of diagnosing these cases 
as psychoneurosis with hysterical hyperesthesia. The accepted approach to 
proper treatment is first to do a sympathetic block of the ganglia supplying 
the affected area. If partial or complete relief is afforded the diagnosis 
becomes established. Sympathetic ganglionectomy is then the treatment of 
choice. Overall results of repeated blocks do not justify the delay by this 
trial. 
A case report of causalgia is presented. This patient received relief 
following novocaine blocks. This relief of pain lasted for six months and 
then a sympathectomy which gave permanent relief of causalgic pain was done. 
White, Heroy and Goodman (U3) describe thirteeft cases of causalgia which 
were treated at a U. S. Naval Hospital. The history of causalgia is reviewed 
from the first descriptions by Mitchell, Moorehouse and Keen (31). Major 
causalgia with its typical triad of symptoms consisting of a disagreeable 
burning pain with hyperesthesia in the hand or foot, trophic changes, and 
autonomic stigmata of excessive vasomotor activity follows partial injury 
to the mixed peripheral nerves in penetrating wounds with a rate incidence 
at little less than 5%, Thermal and psychic stimuli which increase the 
sympathetic discharge from the hypothalraic centers aggravate the pain. It 
is admitted that the condition may improve without treatment, however, the 
process is so slow that the patient may become addicted to narcotics, suffer 
personality changes, or suffer serious crippling, irreparable damage to the 
bones, joints and soft tissue. The authors recommend preganglionic sympath- 
ectomy as an effective method of treatment and feel that it should be done at an early date. In this study, repeated paravertebral chemical blocks 
have not been effective therapeutically but are recommended as a valuable 
diagnostic test. The results of sympathectomy on the thirteen cases pre- 
sented showed complete relief in eight patients, the remaining five having 
some residual paresthesia and hyperesthesia severe enough in only one case 
to retard rehabilitation. 
It is the authors1 opinion that relief of the burning pain following 
sympathetic denervation is due to elimination of the efferent sympathetic 
discharge from the hypothalmic centers rather than to any interruption of 
pain fibers* They further state that they can find no evidence for the 
existence of centrally conducting sympathetic axones in the peripheral nerves. 
It is pointed out that the causalgic state is relieved under conditions which 
reduce sympathetic tone - quiet, warm environment, alcohol ingestion, sleep, 
and febrile states. 
Doupe, Cullen, and Chance (37) ascribe causalgic pain to direct cross 
stimulation of sensory fibersby efferent sympathetic impulses at the point 
where the nerve trunk is injured. As further corroboration of this theory, 
Katz and Schmitt (U5) have shown that under certain circumstances efferent 
nerve impulses can alter the excitability of adjacent sensory axones, 
Granit, Leksell and Skoglund (u6) have given direct experimental proof of 
such cross stimulation. The authors feel that when a nerve trunk is involved 
in the causalgic state its sensory fibers may become so irritable that a 
similar ”short circuiting1’ mechanism will be set up in the proximal neuroma 
after neurectomy at a higher level. 
Turner (UU) states that in the past few years there has been renewed 
interest in the syndromes of pain and dystrophy of the extremities first 
described by Mitchell, Paget, and Sudeck, The most important contributions 
to the basic physiologic fault have dealt with new concepts of transmission 
of nerve impulses in previously unrecognizable pathways. Some of these new 
concepts of the mechanism of pain in causalgia are discussed briefly with the 
admonition that further study of patients with such pain offers a fruitful 
field of collaboration among psychiatrists, internists, and surgeons. 
The shoulder-hand syndrome is characterized by a unilateral painful 
disability of the shoulder associated with swelling, limitation of'motion, 
and trophic changes in the hand and fingers. Steinbrocker, Spitzer and 
Friedman (U7) present the results of 18 cases in a preliminary study with 
iHe following conclusions* Repeated stellate and upper dorsal sympathetic 
block seems to be the treatment of choice in the shoulder-hand syndrome. 
Complete recovery from the painful shoulder dysfunction occurred in almost 
all cases. Relief from pain and restoration of function was obtained by 
supplementary brachial plexus block in one case which had not been helped 
by sympathetic block. The vasomotor phenomena such as swelling of the hand 
were successfully treated with sympathetic blocks if done early. In long 
standing cases the contractures and trophic changes are usually irreversible 
although the associated pain and shoulder dysfunction are relieved even at 
the late stage. The cases which are a sequel to nyocardial infarction proved 
to be the most Resistant to treatment, Novocaine blocks to the sympathetic 
ganglia were administered at two to seven day intervals until recovery. Six 
to twelve blocks, or more, may be necessary to obtain relief. If the chemi- 
cal block proves to be only temporary in its benefit, sympathetic surgery has been advocated when the patients physical condition permits. Supple- 
mentary orthopedic, physical therapeutic and rehabilitative measures are 
desirable. 
Miscellaneous Neuro-Museular Conditions 
Kovacs (h8) states that physical therapeutic agents play an indispensable 
role in the diagnosis and treatment of many affections of the neuromuscular 
system, "Total rehabilitation” has broadened the field of physical medicine 
to include occupational therapy and reconditioning. Three types of neuro- 
muscular disorders as they relate to physical medicine are discussed. 
(1) Peripheral Nerve Injuries; Electrodiagnosis enables a differentia- 
tion between more serious lesions leading to a reaction of degeneration and 
minor injuries which recover spontaneously. Physical therapy must be employed 
early so that when the nerve regenerates there will be a mechanism capable 
of adequate movement. In the treatment of peripheral nerve injuries the aims 
are to improve circulation by heating, diminish wasting and fibrosis by 
electrical stimulation and maintain mobility of joints by active and'passive 
exercise and massage. The details of treatment by means of the principal phy- 
sical measures are presented. 
(2) Infantile Paralysis; The early training of patients to use every 
available muscle fiber with the greatest possible efficiency is the crux of 
the newer treatment of polionyelitis. The author discusses the uses of 
underwater exercises, electrical stimulation, moist heat, and graduated 
exercises. 
(3) Hemiplegia; Physical therapy is necessary for early rehabilitation 
and reeducation of affected extremities, in hastening convalescence and 
contributing to mental ease. The methods of application of physical thera- 
peutic agents - heat, massage, splinting, passive motion, - are discussed. 
Pendse (U9) discusses some of the problems of differential diagnosis of 
muscle weakness. Secondary muscle weakness usually occurs in convalescence 
from acute illnesses or as a result of metabolic derangement as in diabetes, 
or of infections as in tuberculosis, or of new growth as in cancer, or of many 
other systemic diseases. 
Loss in muscle power may be due to many diseases of the nervous system. 
The wasting of muscles in this group is thus due to nerve tissue lesion and 
the involved muscles are those innervated by the affected nerve cells. This 
group of muscle diseases is termed nyelotrophic, If it be a lower motor 
neuron involvement there is flaccidity of muscle. If the brunt of the disease 
is borne by the pyramidal fibers, there is the picture of upper motor neuron 
involvement - spasticity, exaggerated reflexes, loss of voluntary power, but 
no wasting. 
In the group of muscle diseases known as myotrophic muscle disease it 
is presumed that something goes wrong with the normal nutrition of the muscle. 
The muscle starts wasting and loses its power. In some cases there may be 
outward hypertrophy aptly termed pseudohypertrophy. This group of myopathic 
diseases runs in families and usually occurs in males. The individuals usually start showing symptoms at age of ten or twelve. 
In myopathic or myelotrophic muscle disease the clinical picture is 
chiefly muscle weakness with absence of muscle tenderness. In peripheral 
neuritis, muscles are fairly tender. Sensory disturbances are most dis- 
tressing in subacute combined degeneration and multiple neuritis. In acute 
nyelitis and compression nyelitis there are sensory disturbances and sphinc- 
ters are generally involved. The diagnosis of muscle disease is greatly 
helped by the fact that the signs and symptoms that are present arise due to 
the involvement of the muscles themselves or the motor neurone. Myopathic 
and nyelotrophic muscle diseases are usually symmetrical in involvement and 
the muscles are affected in groups. The muscle groups affected in rayelo- 
trophic and myopathic disease are different - the former is related to nerve 
supoly while the latter is involvement of groups of muscles such as the 
shoulder muscle weakness in pseudohypertrophic paralysis. The spinal type 
sets in, in later life while the nyopathic groups start at about age 10* 
The treatment of either type is very unsatisfactory. 
Burrus (50) reports two cases of progressive muscular dystrophy in 
Negroes, The clinical and pathological aspects of the disease are discussed. 
As far as can be ascertained by the author these two cases represent only the 
fourth and fifth cases of progressive muscular dystrophy in Negroes reported 
in the literature. 
Gilmore (51) reports briefly on three cases known to him in which there 
was unilateral quadriceps atrophy after having taken protamine zinc insulin 
over a prolonged period of time. One case had objective findings of atrophy 
but no apparent weakness noticed by the patient. Two cases had objective 
findings of unilateral quadriceps atrophy with inability to normally support 
the body weight except in hyperextension of the knee. No discussion or solu- 
tion is offered. 
Hansson (52) gives a follow-up study of 23 patients with recovery from 
paralysis ol the serratus magnus muscle. The author discusses briefly the 
anatomy and comparative anatomy of the serratus magnus muscle with resultant 
deformities of the paralyzed muscle. As to the etiology, most cases were 
idiopathic, however, there was usually a history of exposure with a possible 
avitaminosis. Trauma, including post-operative and post-partum, is respon- 
sible for a considerable number of cases. Serratus magnus paralysis may also 
follow tetanus antitoxin injections and poliomyelitis. The deformity produced 
by such a paralysis is protrusion of the medial border of the scapula and a 
rotation of the scapula upward and laterally. Immobilization, therefore, 
should be by a support that presses the scapula to the thoracic wall and also 
derotates the scapula. Additional treatment includes electrical stimulation 
and specific exercises. The brace used presses the scapula against the 
thorax by means of a metal spring of semicircular shape, it goes over the 
shoulder to exert pressure anterior and posterior on the thorax. In addition 
there is a leather sleeve on the arm to prevent elevation of the arm. Illus- 
trative pictures of the brace are presented. 
Biochemical data has suggested that a state of a denervated muscle can 
be regarded as a "local hyperthyroidism”. Two possibilities are suggested 
by Huff (53). (1) Thyroxin from the thyroid gland has a greater effect on denervated 
muscle, 
(2) The extra thyroidal production of thyroxin in the denervated muscle 
is different than that in normal muscle. 
Experiments on rats showed that thyroxin accelerates, while thiourea 
inhibits atrophy. Acceleration of atrophy is also brought about by arsenic 
and dinitrophenol while retardation of atrophy occurs on a protein free diet. 
A syndrome consisting of pain and flaccid paralysis about the shoulder 
girdle and upper arm is described by Parsonage and Turner (5U). The clini- 
cal picture is that of sudden onset of pain about the shoulder which may rad- 
iate down the arm or into the neck. The pain may last about two weeks and 
then there is a flaccid paralysis of some of the muscles of the shoulder or 
arm. The important feature of onset is the absence of fever and constitu- 
tional symptoms. Clinically the pathological process can involve one or more 
peripheral nerves, two or more spinal roots, or the spinal cord. This condi- 
tion appears to be a distinct clinical entity which became more common dur- 
ing the war years. No specific therapy for the condition is known. The 
treatment used has been similar to that used in poliomyelitis. The prognosis 
is much the same as anterior poliomyelitis with recovery continuing up to 
two years. The etiology of this disease remains obscure. A virus infection 
has been suggested as the cause, A similar syndrome may occur after serum 
injection and the two conditions may be identical. The name ’’Neuralgic 
amyotrophy” is suggested. 
An unusual case of acute ascending paralysis occurring twice in the same 
individual with complete recovery from both episodes is reported by Weigner 
(55). The incomplete and unsatisfactory state of our knowledge regarding 
the whole problem of ascending paralysis is discussed in the light of the 
widely varying etiologies and pathological pictures reported in the litera- 
ture, It is suggested that a disease entity characterized by a rapidly pro- 
gressing and highly fatal paralysis does exist and that the term Landry's 
Paralysis or acute ascending paralysis should be properly reserved for this 
type only. It is further suggested that this type may be of viral origin 
and related to anterior poliomyelitis and infectious polyneuritis. Causes 
of other types of ascending paralysis are discussed and the fact that diag- 
nosis and treatment of these other types constitute a problem for the intern- 
ist as well as the neurologist is pointed out. The symptoms of acute ascend- 
ing paralysis are described and differential diagnosis discussed. Appreciable 
danger of an erroneous diagnosis of hysteria during the early phase of the 
disease is emphasized. 
Sanders (56) states an aggressive few of the paraplegics may be 
given wheelchair, braces, and crutches and then need little coaxing to regain 
a place in society. Most of the paraplegics, however, feel inadequate, in- 
competent and dependent. It is necessary to help this latter group by stim- 
ulation, evaluation and training to rebuild the necessary muscular control 
and reestablish the functional mechanics of the body to the greatest degree. 
It must be pointed out to the patient that life spent in a wheelchair 
is not only undesirable, but also detrimental to the maintenance of optimum 
health. Wheelchair exercises are necessary preparatory to exercises for 
getting to the floor; moving from wheelchair to another chair; learning to manage braces; and participating in games and recreational activities. Mat 
exercises are beneficial in developing the muscle groups needed in ambula- 
tion, The ambulation instructor must participate in the total rehabilita- 
tion by carrying on the bladder training established by the urologist. In 
crutch walking, balance leverage and pendulum action are the tools with which 
we must work during the early period of ambulation instruction. We must 
schedule activities so that the patient's fears are dispelled in the know- 
ledge that his braces support him, * 
Bed patients begin the rehabilitation by breathing exercises which bring 
into play the muscles of the shoulders and vertebral borders of the scapulae. 
Trapeze exercises in bed are employed to add in changing positions and fur- 
ther develop the upper extremity. The author discusses the graduated exer- 
cises and patterns of motion which are employed from the stage of bed patient 
to the standing paraplegic patient. 
Since the patient is likely to spend months in bed it is necessary that 
the instructor vary the exercises, altering dosage as the situation demands, 
since progress is often interrupted by intercurrent illness or operation. 
When the paraplegic has been reconditioned by appropriate exercises, he 
is ready for the task of learning to put on his clothing and necessary braces. 
Much valuable exercise is obtained when braces, corsets, or other appliances 
have to be adjusted. The author states that his paper is to be continued 
frith an analysis of wheelchair and mat class exercises so important in devel- 
oping muscle tone and endurance which are essential for crutch walking. 
Harvey, Tumulty, Bang and Leftwich (57) report on an epidemic in which 
typical pleurodynia and cervical myalgia appeared currently among the staff 
and patients of the Johns Hopkins Hospital during October and November 19U7* 
Among the numerous synonyms for the disease are epidemic nyalgia, epidemic 
pleurodynia, devils grip, Bornholm disease, epidemic phrenic neuralgia, and 
epidemic diaphragmatic spasm. It is an acute infectious disease, thought to 
be of virus etiology, which has appeared in epidemic form in many parts of 
the world. The diagnostic feature is paroxysmal pain in a muscle group or 
groups. Most commonly the pain is localized to the lower chest and epigas- 
trium by coughing, sneezing, and breathing. The pain often radiates to the 
shoulders or neck, upper or lower abdomen, or back. Typically the pain is 
migratory and sometimes fleeting. Severe frontal headache is the most common 
associated symptom. Fever of 102-103 degrees is a common manifestation. 
Physical examination rarely discloses abnormalities, other than protective, 
splinting,. The infection runs its course in two to seven days, but may last 
up to three weeks. The occuirenceof pleurodynia and cervical nyalgia is 
often seen in the epidemic. The opinion is expressed that two clinical 
syndromes are not separate entities but variant forms of the same infectious 
process, the dominant manifestation of which is muscle pain. 
Travell and Rinzler (58) give three illustrative case reports todemon- 
strate the striking resemblance which pain syndromes of the chest muscles 
may bear to effort angina and acute myocardial infarction. The cases pre- 
sented are patients who demonstrate chest and arm pain and in whom no evidence 
of organic heart disease can be found, but in whom the diagnosis remains un- 
settled because the purely somatic pain syndromes which result from fatigue 
and strain of voluntary muscles are frequently overlooked. This report deals with the differential diagnosis and treatment of 
pain syndromes of the chest which are primarily somatic in origin, but which 
resemble effort angina or acute myocardial infarction. In acute episodes of 
pain suggestive of myocardial infarction, the presence or absence of signs 
of tissue necrosis and circulatory collapse are of the utmost importance in 
weighing the diagnosis in one direction or the other. The absence of trig- 
ger areas tends to rule out skeletal muscle as a cause of t he pain unless the 
involved muscle be located in the retro-sternal area. There is often "rheu- 
matic tendency” of the patient with somatic muscle pain. In chronic effort 
syndromes of somatic cause there is an enormous variability in the exercise 
limit over a short period of time. Such variability is rarely seen in coron- 
aiy artery disease. This intractable chest pain of somatic origin may be 
relieved by local block therapy (procaine infiltration or ethyl chloride 
spray) into the trigger areas. Relief of these pains in itself does not prove 
that the cause of the pain is primarily somatic, since under suitable condi- 
tions cardiac pain may likewise respond to local block of the appropriate 
somatic structures. 
Denny-Brown (59) reports two cases of primary simple degeneration of 
the dorsal root ganglion cells associated with a primary degeneratidn of the 
muscles (Polymyositis). The co-existance of "myositis" was not suspected 
during life. A form of clinical polyneuritis that effects sensory function 
alone is sufficiently unusual to attract more than passing attention. Most 
forms of polyneuritis even though predominantly sensory do present some evi- 
dence of muscular weakness and wasting. Both cases presented a spreading 
numbness and sensory loss of the extremities, on one of the face, without 
pain but with severe and progressive ataxia. In both instances bronchogenic 
pulmonary carcinoma was present. The close similarity of the condition in 
the two patients suggests that the coincidence of carcinoma was more than 
chance association. 
Detailed case histories and autopsy findings are presented along with 
several photomicrographs to illustrate the pathologic findings. In both 
instances the lumbo-sacral ganglia were the most heavily affected, but the 
disorder was widespread. The whole process of ganglionic degeneration pre- 
sented the appearance of a primary atrophic process of nerve cells, without 
inflammation or vascular reaction. The anterior horn cells did not show any 
changes of the type shown in the dorsal root ganglion cells. The muscles 
showed a proliferation of sarcolemmal nuclei and increased cellularity of 
the connective tissue of a kind seen in chronic myositis, or rapidly pro- 
gressive myopathy. 
The type of degenerative neurons and muscular affection is entirely 
consistent with that resulting from metabolic disorder and present changes 
in man that are comparable to those associated with deficiency in pantothenic 
acid in swine. It is indeed possible that bronchogenic carcinoma produces a 
by-product which interferes with the biological conjugation of pantothenic 
acid in metabolism. Metabolic studies in similar cases in the future are 
indicated. 
Repeated efforts have been made to integrate the divergent views on 
the etiology of multiple sclerosis, but we are still left a few seemingly 
contradictory approaches and opinions of the problem. Andren (60) presents a brief survey of the pertinent facts elicited in the investigation of the 
etiologic factors in disseminated sclerosis with the view of correlating some 
of the more conflicting concepts. The vascular occlusion theoiy may be re- 
lated to that of vasoconstriction or spasm. The vulnerability of the white 
matter, and possibly of the sympathetic nervous system as a whole, to noxious 
factors of metabolic, infectious, or other irritative characters is emphasized. 
The theoiy of local allergy as described by Ferraro and others, does not 
preclude the possibility of the above concepts, nor does the theory of virus 
etiology necessarily change the idea of the mechanism involved, although it 
is possible that the virus theoiy may hold only in limited cases. 
The author emphasizes that a careful study of the history with investi- 
gation of the more minor symptoms, the nature of onset as well as remissions , 
may reveal additional etiologic factors that may become of preventive, 
therapeutic and prognostic significance. Careful laboratory studies made on 
cases of multiple sclerosis has revealed inconstant findings, suggesting 
possible multiple factors of etiology. 
Spasmodic torticollis has been recognized for centuries and has failed 
to respond to many forms of treatment. Modern neuro-surgical techniques, 
however, have brought many successful results. Bunts (61) briefly reviews 
the clinical picture which is seen in spasmodic torticollis, Various theories 
of the causation of this disease are presented. Experiences with conserva- 
tive therapy at the Cleveland Clinic have been generally unsatisfactory. The 
treatment recommended is division of the anterior roots of the first three 
cervical nerves on both sides. At a second stage operation after one week 
interval the spinal accessory nerve on the involved side is resected and 
ligated in the region of the stemomastoid muscle. Case reports with suc- 
cessful results following the above therapeutic regime are presented. Im- 
mobilization in plaster or fixation with bone graft have not been found 
necessary. 
According to Rabat and Knott (62) the following principles are the 
basis for active exercise of patients with spastic paralysisj- 
1. By repetitive use of the new pathway, improved function results, with 
increase in power and endurance and greater ease of performance• 
2. Inactivity leads to loss of function and atrophy, 
3. Voluntary motion performed by contraction of the agonist muscles results 
in reciprocal inhibition and relaxation of the antagonist. 
Iu Training of new patterns of motion is dependent on formation of new 
functional pathways in the central nervous system. 
5, Successful repetition of a pattern of motion renders its performance 
less difficult requiring less concentration until the pattern becomes 
habitual and automatic. 
6. The amount of activity in a muscle, motor nerve or central motor path- 
way depends primarily upon the percentage of the units being excited. 
The greatest part of most reeducational programs of spastic paralysis 
is devoted to the teaching of sitting, standing, and walking by means of 
constant practice, rather than reeducation of individual muscles or groups 
of muscles, in single motion. Teaching a patient to sit or stand by having 
him do so is asking him to perform a complex combination of muscular contrac- 
tions, when he cannot perform the simple motions of the combination, thus 
i5o: resulting in failure. New principles in the treatment of spastic paralysis 
are as follows•- 
1. Maximal activation of simple motions. 
2. Re-inforcement of voluntary innervation. 
3. In patients with a limit in range of motion, the emphasis is 
placed upon range and power of active motion. 
U. Correction of muscle imbalance in antagonists. 
5. Correction of substitution, 
6. Correction of overflow. 
7. Heavy resistance therapy to develop combination of two or 
more motions. 
8* Training in habit patterns. 
The principles listed above are discussed and the application of these 
principles is outlined by the authors. 
Progressive muscle dystrophy is characterized by wasting muscles but 
no significant change in nitrogen excretion. Ames and Risley (63) investi- 
gated the distribution of nitrogenous products in the urine in such cases. 
It was found that there was marked increase in amino acid excretion in 
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dystrophy, Federation Proc., 7: lii2, Mar. 19U8 SECTION 8 
FRACTURES 
Prepared By Oscar S# Reeder, Colonel, USAF (MG) 
Lucius C. Hollister, Jr., Major, USAF (MC) 
Robert W. Parvin, Major, M*C*, USA 
Elwin W. Midgley, Captain, USAF (MC) 
Fractures of the Upper Extremity 
Fractures of the Clavicle - Ripstein (1) lists the following indica- 
tions for open reduction and fixation of fractures of the clavicle: (1) 
oblique fractures of the middle third with marked displacement in which 
reduction cannot be maintained, (2) fractures of the outer third which 
present the same problem as acromio-clavicular dislocations, (3) any frac- 
ture in which a perfect cosmetic result is particularly desired, (U) cases 
in which immobilization of the arm would impose a severe economic handicap. 
The method of fixation favored by the author is an intramedullary wire pro- 
cedure. Under general anesthesia with the patient on his back and a sand- 
bag beneath the scapula on the affected side, a one inch incision is made 
and the fracture exposed. A large Kirschner wire is then passed in retro- 
grade fashion through the lateral fragment, through to the postero-lateral 
aspect of the shoulder and then drawn out until the medial end of the wire 
is flush with the medial end of the lateral fragment. The fracture is then 
reduced and the wire pushed across the fracture site into the medial frag- 
ment for approximately two inches. The projecting end of the wire is then 
cut off and allowed to lie subcutaneously. A sling is worn for i*8 hours 
post-operatively after which full movement is allowed although strenuous 
exertion is discouraged. The wire is withdrawn under local anesthesia four 
weeks later. 
Fractures of the scapula - Wright (2) presents a case of fracture of 
the coracoid process of the scapula with no tearing to the acromio-clavicular, 
trapezoid or coracoid ligaments. The injury was incurred in a football game 
when the patient was thrown into the air and landed on his left shoulder. 
The patient had no pain at rest, but was unable to move his left arm. Clin- 
ically the shoulder was somewhat elevated and the lateral end of the clavi- 
cle appeared to be situated on top of the acromium although there was no ten- 
derness or pain to pressure at this point. 
Fractures of the Humerus - Hammond and Clemmons (3) present a brief re- 
view of the literature on cases of fracture due to electric shock and present* 
a case of bilateral humeral fracture due to this cause. Their case is that 
of a 56 year old woman who received a violent shock while holding one hand 
in a washing machine and the other on a water faucet. During the shock she 
shook considerably but received no direct trauma to the shoulders. Examina- 
tion disclosed severely comminuted fractures of both humeral heads, the right shoulder showing fracture-dislocation with multiple frac- 
tures involving the surgical neck and humeral head* Closed reduction was 
performed on the right shoulder and both shoulders were abducted to 90 
degrees with continuous traction suspension* The traction was continued 
for six weeks on the left arm and for eight weeks on the right, with unevent- 
ful convalescence* In the absence of any direct trauma to either shoulder 
it is plausible that the bone pathology was due to the combination of the 
effects of muscular contraction and of the passage of an electrical current 
through the bone* 
Mas land (Ij.) describes again his reduction and fixation splints for 
non-operative treatment of fractures of the humerus and for fractures in 
and about the femoral neck. He states that the construction of the splints 
is based upon the principle of placing comfortable anchorages upon adjacent 
bones above and below the fractured member, metal strips being attached to 
these anchorages on both sides of the limb with sleeves that enclose the 
overlapping ends* In this way the necessary extension can be secured and 
then retained by clamping the sleeves. 
Andreasen (5) reports a case of avulsion fracture of the lesser tuber- 
osity of the Humerus occuring in a 56 year old woman as a result of effort 
with the arm fully abducted above the shoulders, the hand being fixed and 
the body moving at the time* The patient incurred severe deltoid atrophy, 
contusion of the circumflex nerve with resultant neuropraxia, hemarthrosis 
and loss of internal rotation* After two months in an abduction splint and 
daily active exercises for the next two months she regained deltoid power, 
but never regained internal rotation at the scapulo-humeral joint* The 
avulsed fragment underwent aseptic necrosis and then was absorbed in twelve 
months• 
Swenson (6) proposes a method of blind pinning of supracondylar frac- 
tures of the humerus in children where extensive swelling of the elbow pro- 
hibits immobilization in acute flexion after reduction* After reducing the 
fracture he inserts a wire through each condyle in an oblique fashion being 
directed posteriorly and inward to insure penetration of the shaft of the 
humerus * The wires are unequal in size to facilitate x-ray check of the 
position. After such fixation of the condyles, the wires are cut off even 
with the skin and the skin drawn over them. Sterile dressings and posterior 
splints with the elbow in 90-100 degrees flexion are applied* The wires 
eliminate the need for more acute flexion of the elbow and are removed under 
local anesthesia after three weeks* Care must be taken to avoid injury to 
the ulnar nerve* 
McDonnell and Wilson (7) reviewed their cases of fractures of the lower 
end of the humerus in children* An excellent discussion of the anatomy of 
the elbow is presented, emphasizing that it is important to remember that 
the epiphyseal line separating the trochlea, capitellum and lateral condyle 
from the diaphysis runs transversely just above the lateral condyle cartilage 
and is within the synovial capsule* They point out that contrary to prevail- 
ing opinion, supracondylar fractures can produce serious growth disturbances 
if the fracture lines extend into the epiphyseal centers. Anterior-posterior 
displacement may result in permanent limitation of extension or flexion; 
lateral displacement may produce varus or valgus, although a functional re- 
sult could still be good if no late nerve palsy develops. The authors 
found poor results in 50% of the cases of lateral condylar fractures treated by closed reduction, thus pointing out the necessity for open reduction of 
these cases. They also noted that in spite of good reduction of a supra- 
condylar fracture, avascular necrosis of the trochlea raay occur later* 
(although this apparently is very rare). Fractures of the medial epicondyle, 
unless the fragment enters the joint cavity, do not cause a serious disabil- 
ity. 
Fractures of the Olecranon - Strug (8) reviewed the literature on anter- 
ior dislocation of1 the elbow finding a total of 3U reported cases, seven of 
which were accompanied by fracture of the olecranon, with his case making a 
total of 35. He discusses the mechanism and pathology of the condition noting 
that the majority have occurred as a result of a direct blow on the elbow 
although bizarre types of injury may cause the condition. External lacera- 
tions of the ligaments about the joint, injury to the muscles, possible sep- 
aration of the muscles from their bony attachments and severe hemorrhage into 
the soft parts comprise the remainder of the pathology. Rupture of the bra- 
chial artery, tear of the brachial artery or arterial spasm comprise some of 
the possible vascular complications. If the radial pulse does not return on 
reduction one should suspect major vascular damage or massive hematoma call- 
ing for immediate operative intervention. In arterial spasm, upper thoracic 
and stellate sympathetic blocks may be beneficial. Unusually difficult re- 
duction should lead to the suspicion of the distal end of the humerus 
'•button-holing*1 through a lacerated triceps. The case reported was that of 
an 11 year old boy who struck his elbow against a tree in a fall from a 
bicycle. Here there was an anterior dislocation of the elbow joint with a 
fracture of the olecranon process remaining in normal relation to the humerus 
while the major forearm fragments were carried forward. Reduction was fol- 
lowed by the application of an anterior and posterior splint for three weeks. 
The author states that there was full return of function. 
Michele (9) presents a method of wire fixation used in twelve cases of 
olecranon fractures treated during the past seven years. It is essentially 
a double loop method using a single continuous steel wire placed through a 
transverse drill hole in the distal fragment, thence through the site of 
attachment of the triceps tendon to the olecranon and then through a second 
more distal drill hole in the distal fragment. After anatomical reduction 
the ends of the wires are twisted and drawn tight and turned under the perios- 
teum. Post-operatively passive motion is begun in two to three weeks with 
full motion before the sixth or seventh of treatment. 
Fractures of the Radius - Hakala (10) presents a case of a 2 5 year old 
white male officer with a fracture of the head of the radius which appeared 
relatively innocuous radiographically and was to be treated conservatively 
until clinical examination showed complete loss of active supination, 
loss of active pronation, moderate limitation of flexion and extension and 
severe pain on passive motion beyond these extremes. Consequently, an arth- 
rotonjy was performed through a postero-lateral incision at which time it was 
found that a piece of articular cartilage, ij x ij cm. in size, had been 
separated from the lateral humeral condyle and was impacted edgewise into 
the fracture-line in the head of the radius thus accounting for the restric- 
tion of motion and severe pain. Hakala resected the head of the radius and 
trimmed the ragged edges of the cartilage defect in the lateral condyle of 
the humerus. In discussing the case and radial head fractures in general. Hakala stresses the need to watch for possible myositis ossificans* 
Fractures of the Ulna - Kitchen (11) presents a case of fatigue frac- 
ture of the ulna occurring in a 26 year old farm worker while he was shovel- 
ing manure. The patient complained of pain in the forearm, mostly at night. 
On examination there was a fusiform swelling of the middle third of the 
forearm with heat, tenderness and slight edema. X-ray showed a fracture of 
the ulna with considerable fusiform callus formation in the region of the 
fracture* In comparing this fracture with fatigue fractures of other bones. 
Kitchen notes the similarity of this case with fatigue fractures of the meta- 
tarsal bones and the dissimilarity with fatigue fractures of the long bones 
of the lower limb* The explanation may be that in the case of fractures of 
the metatarsal and of the ulna, the forces act at an angle of approximately 
90 degrees to the long axis of the bone$ whereas in the tibia, fibula and 
femur the stress is applied almost along the axis of the bone* This may be 
the reason for a clearly defined line of fracture in the metatarsal and ulna 
which is not seen in the tibia, fibula, and femur. 
Fractures of the Radius and Ulna - Humphries (12) presents a case of 
a patient who sustained a severe open fracture o? both bones of the forearm 
with displacement of the lower fragments, angulation and an inch of shorten- 
ing* On admission, operation was performed, using an ivory peg to secure 
the ulna* On removing the plaster after six weeks the ivory peg broke and 
movement at the ulnar fracture* The ivory peg in the ulna formed 
a sequestrum which had to be removed but eventual union occurred* 
Trevor (13) presents a case of a i*2 year old woman who caught her 
right forearm and hand in a machine. On examination she was found to have 
a skin wound completely encircling the forearm just above the wrist joint. 
There was comminution of the lower end of the radius, a fracture-dislocation 
of the lower end of the ulna, the proximal carpal joints were opened and all 
extensor tendons were severed* The median and ulnar nerves were intact. The 
radial nerve was severed at the wrist but the bulk of the flexor tendons 
were intact. At operation on the day of the injury the lower ends of the 
radius and ulna were brought together, dead muscle excised and sutured fol- 
lowed by application of plaster. The fracture was manipulated ten days later 
and remanipulated 28 days after injury* Seventy-seven days after injury free 
tendon grafts were taken from the tendon of the palraaris longus and inserted 
between the cut ends of the extensor tendons. At the same time one and one- 
half inches of the lower end of the ulna were excised. The patient returned 
to work approximately seven months after the injury but still required re- 
pair of the long extensor tendon of the thumb. 
Miscellaneous - Stressing that Colles* fractures should not be too 
lightly regarded. Strange (li*) points out that shortening of the radius, 
loss of the normal 15> degree tilt of the articular facing and varying amounts 
of separation of the ends of the radius and ulna may occur. Reduction con- 
sists of breaking up the impaction, restoring the normal radial articular 
facing and immobilization in a padded plaster from elbow to the metacarpo- 
phalangeal crease of the fingers. Moderate pressure is applied over the 
distal ends of the radius and ulna to closely approximate these bones. Fac- 
ing and length is maintained by holding the hand in 60 degrees of flexion 
i6o and marked ulnar deviation at the radio-carpal joint. Immediate post- 
reduction films are stressed as well as repeated follow-up films with the 
critical period being between the seventh and tenth days when soft callus 
has begun to form. Immobilization is carried on for four to six weeks, 
after which the cast is bivalved and x-rays determine the future course of 
either physiotherapy or further immobilization. The possibility of Sudeckfs 
atrophy characterized by persistent stiffness, swelling and circulatory 
impairment is pointed out. The author treats this condition by blocking the 
sympathetic ganglia or by the use of tetra-ethyl ammonium bromide. Some of 
the more common pitfalls are pointed out, such as mistaking a Smith fracture, 
(reverse Colles*) for a Colles1 fracture and displacement of the radial 
epiphysis in children. 
White and Stevenson (15) proposed a method of treating forearm fractures 
by means of lateral traction exerted through the untapered cylindrical screw 
inserted in the desired fragment. They started using this method in comr- 
pound fractures where they wished to avoid metallic fixation but they were 
so satisfied with the results they have been applying it electively also. 
Under novocaine or sodium pentothal anesthesia a stainless steel screw (with 
no tapering) is inserted into either the distal or the proximal fragment; 
whichever will elevate the other fragment when traction is applied. It can 
only be used where the fragments are in contact. After inserting the screw 
a padded long arm cast with a wire bow resembling a banjo splint is applied 
and traction gained by a rubber band between the wire bow and the screw. 
Traction is maintained until there is x-ray evidence of bony callus. Because 
of the limiting effect of the interosseous septum, overpull has presented no 
problem. It has not been found necessary to employ anesthesia in the removal 
of the screws. 
Funsten (16) reviewed sixty-six cases of slipped radial epiphysis to 
determine end results and factors influencing them. Forty-eight were male 
and sixteen were female. The ages of the cases ranged from three and one- 
half years to eighteen years of age. The largest incidence was in the ten 
to fifteen age period. Follow-up was possible in only forty cases. The 
original displacement was complete (epiphysis more than half displaced) in 
forty-five cases and incomplete (epiphysis less than half displaced) in 
twenty-one. The reduction was complete (less than half a centimeter dis- 
placement) in forty-five cases and incomplete in twenty with no reduction 
attempted in one case. In the forty cases followed there were five with 
deformity. In three the deformity consisted of only slight shortening, the 
radial deviation was mild. In one case it was severe, and in another it 
was quite severe. The latter case was a compound injury. Funsten concludes 
that growth disturbances in epiphyseal injuries occurs less frequently than 
would be expected. Slight imperfections in reductions were not a calamity. 
He feels that attempts at reduction after twelve days following injury leads 
to greater deformity than non-interference. 
Enyart, Brown and Trunnell (17) analyzed 52 cases of fracture of the 
carpal navicular bone. Recognizing that roentgenograms at the time of injury 
may fail to show a fracture of the navicular, they recommend that all patients 
giving a history of force having been applied to the palm of the dorsiflexed 
hand, and especially those with tenderness in the anatomical snuff box, should be placed in a cast even though there is no evidence of fracture* 
Fluoroscopic examination of 17 of 23 cases in casts revealed very little 
motion of the navicular bone in skin-tight casts in contrast to appreciable 
motion in padded casts* They therefore recommend the use of skin-tight casts 
to prevent motion of the carpal navicular fragments during the healing period* 
A general discussion of fractures of the navicular (carpal) is pre- 
sented by Bonnin (18)* The diagnosis of fracture of the navicular bone in 
the absence of x-rays may be suggested by a history of a fall on the wrist 
with subsequent pain in the region of the anatomical snuff box* The navicu- 
lar is fractured in one of three ways: (1) by compression between the car- 
pus and the lower end of the radius (2) by shearing strain due to excessive 
movement between the 1st and 2nd carpal rows, between which the navicular 
lies as a tie bar (3) by violent ulnar deviation of the wrist which avulses 
the navicular tuberosity (Sprain fracture)* The varieties of fractures are 
grouped as (1) the common fissured, subcartilaginous fractures of the waist 
without displacement (2) the less common complete fracture with separation 
and displacement (3) fractures of the tuberosity of the navicular (ii) frac- 
tures of the distal pole of the navicular (5) fractures of the proximal pole 
(i*e. proximal to the waist)* The first type comprising 80$ of navicular 
fractures does not require complete fixation of the thumb to gain union. 
The first metacarpo-phalangeal joint is therefore left free* Union is det- 
ermined radiographically. Fractures of the navicular with displacement are 
associated with perilunar dislocation and form l£$ of all cases. Bonnin 
has found the most successful position for fixation to be one of ulnar 
deviation obtained by ’’plastering the wrist under traction, with the thumb 
held so that it forms a straight line with the radial border” (the forearm 
and hand being pronated)* The thumb as far as the metacarpo-phalangeal 
joint must be restricted. In fractures of the tuberosity of the navicular 
(strain fractures) due to forced ulnar deviation of the hand, reduction is 
obtained by radial deviation and immobilized by ”smaller plaster” (which 
extends to the metacarpo-phalangeal joint of the thumb). Fractures of the 
distal pole are treated in the same fashion as the subcartilaginous frac- 
tures. Fractures of the proximal pole should be treated by early excision 
of the small fragments inasmuch as the loose fragments inevitably undergo 
avascular necrosis. In the event of avascular necrosis, which is more likely 
as the fracture line approaches the proximal pole, the treatment is removal 
of the proximal pole as soon as the diagnosis of avascular necrosis is fully 
established. In the older cases with arthritis of the radio-navicular joint 
the author tries excision of the proximal pole first (excision of entire 
navicular if severe x-ray changes are present). If this is unsatisfactory, 
he removes the proximal carpal row and as a final confession of failure, 
fuses the wrist. 
Dewar (19) reviewed the principles of treatment of fractures of the 
small bones of the hand, stressing early reduction, adequate fixation in 
position of function, avoidance of hand swelling, careful follow-up, care 
of the uninvolved portion of the extremity and early mobilization* 
Jacobs (20) reports a case of fracture of the pisiform bone without 
other carpal injury. The rarity of this condition is indicated by noting 
that this brings the total of reported cases of this to 18. Jacobs claims that the demonstration of the fracture depends on taking an 80 degree 
oblique view of the wrist with the joint in dorsal flexion# One must dis- 
tinguish the fracture from anomalous bones, the secondary pisiform, the 
os triangular® and the separate styloid process of the ulna# 
Anderson and Katz (21) present a brief review of the literature on 
fractures of the greater multangular bone and the opinions of different 
authors as to the mechanism of the production of such fractures ranging from 
indirect trauma to direct violence and as a result of a gunshot wound# The 
symptoms are chiefly swelling and pain on the radial side of the wrist and 
the base of the thumb and pain is aggravated by motion of the thumb# The 
diagnosis is confirmed by x-ray# They cite Greene and Miller as recommend- 
ing treatment by immobilization of the thumb in slight abduction or an angle 
of k5 degrees to the carpal bones for a period of eight weeks# Except for 
possible limitations of apposition of the thumb the prognosis ordinarily is 
good# Two cases are reported of fracture of the greater multangular bone, 
one of which was caused by a gunshot wound and was accompanied by consider- 
able soft tissue damage# 
Goldberg (22) in 19U6 described a new instrument for the treatment of 
metacarpal fractures based primarily on the principle advanced by Jahss. 
It relies on the flexed proximal phalanx to push upward on the distal frag- 
ment (largely head of the metacarpal) but it does not depend on anchorage 
of the metacarpal by the carpo-metacarpal joint capsule# The author des- 
cribes the tendinous anatomy of the metacarpo-phalangeal joint to demonstrate 
how depression of the head of the metacarpal alters the directional pull of 
the lumbrical and the interosseous muscles thus extending the proximal pha- 
lanx and causing relative shortening of the flexor tendons# He discusses 
numerous methods in current usage for maintaining reduction of the fracture# 
The instrument consists of a radio-lucent plastic horizontal arm and a vert- 
ical arm of similar material# The horizontal arm is fixed to the forearm 
with plaster and on it is an adjustable pressure plate for pressure on the 
dorsal aspect of the proximal fragment# The vertical arm bolts to the 
horizontal arm and has an adjustable support bracket for putting pressure 
on the dorsal surfaces of the flexed second and third phalanges with 90 
degrees flexion of the metacarpo-phalangeal joint# In case of a metacarpal 
fracture, after breaking up the impaction and reducing the fracture, the 
instrument as described above is applied maintaining the knuckle in its 
normal prominent position# It is advisable to include the next adjacent 
normal finger in the flexor fixation for a day or two to prevent rotation 
of the fragments. Goldberg removes the vertical arm once daily, holds the 
reduction manually and exercises the fingers# After three to five days when 
the swelling of the hand and spasm of the intrinsic muscles has subsided 
the vertical arm is replaced by a square which bolts to the horizontal arm 
and has a pressure plate which may be used to hold the head in normal posi- 
tion, allowing the fingers free motion# 
Carlton (23) describes a case of a 35 year old porter who sustained 
an oblique fracture of the fourth metacarpal bone while lifting a parcel 
Treighing thirty pounds into a rack of a railway compartment. There was 
no direct violence# The patient*s blood phosphorus was double the normal 
and blood calcium half the normal# This was his first bony lesion# Fractures of the Lower Extremit; 
Fractures About the Hip Joint - Freyfaerg and Levy, (2jU)> discuss the 
general medical management of patients with fractures of the hip* They 
point out that except in rare instances when younger persons receive severe 
and unusual trauma such as would occur in automobile accidents and the like, 
persons who sustain a fracture of the hip are adults in the older age group* 
To determine the incidence and nature of the more common medical problems 
and complications encountered, they made an analysis of all cases of frac- 
ture of the hip treated at the hospital for Special Surgery during ten years, 
ending December 19l|6. Seventy-two per cent of the patients were women; the 
largest incidence occurred between 70 and 80 years. The average age of the 
women was 66 years, ten years older than the average men and three years 
older than the general average. Many were obese women in the post menopause 
period. Significant osteoporosis was frequent and is undoubtedly important 
in the etiology of the fracture. Significant complications occurred in 17 
per cent of all cases. The average age of patients with complications was 
71 years. The common pre-existing complications were obesity, diabetes 
mellitus, hypertensive vascular disease, and arteriosclerotic-heart disease. 
None of these illnesses appeared to endanger the patient or cause death, 
but made the management of the patient difficult when infection or vascular 
accident occurred. The most important complications were those acute ill- 
nesses which occurred after the fracture. These were chiefly pneumonia, 
decubitus ulcers, phlebothrombosis, pulmonary embolism. Most of the cases 
of pneumonia and pulmonary embolism occurred in patients confined to bed. 
The over-all mortality rate was 7*2 per cent. The average age of fatal 
cases was 7l*»5 years and 67 per cent of the deaths were in women. The 
authors believe that prevention of obesity would undoubtedly lower the inci- 
dence of fracture. They are of the opinion that weight reduction should be 
started in all obese patients at the outset of treatment for fracture. If 
osteoporosis is a prominent feature in post-climacteric patients, they 
recommend that the plan of treatment outlined by Reifenstein and Albright, 
using adequate amounts of estrogen and androgen in the form of diethylstil- 
bestrol or testosterone. Prolonged rest in bed should be avoided whenever 
possible to slow down the further excretion of calcium and to prevent further 
aggravation of the osteoporosis. In their series, most fatalities were due 
to pneumonia - 50 per cent. Second most frequent post-fracture complication 
was ohleb©thrombosis which, in some cases, produced pulmonary embolism and 
infarction. The authors are of the opinion that anticoagulants (dicoumeral) 
should be used prophylactically during the first ten to fourteen days after 
the fracture of the hip, especially in bed patients, and certainly in all 
cases of pulmonary embolism to prevent extension of the phlebothrombosis 
and fatal embolism. They advocate protein hydrolysates and amino acid 
mixtures in those cases where protein supplements are needed; adequate 
vitamins to prevent or correct a deficiency state; special attention to 
prevent or correct failing heart should be given to patients with arterio- 
sclerosis or hypertension; the administration of cathartics and sedatives 
should be confined to cases requiring them. 
Johnson (25) gives a general review of experiences in treatment of 
forty-four patients with fractures about the hip joint. The author is 
aware that the follow-up in these cases is not sufficiently long to draw 
any concrete conclusion as to the efficacy of the plan of treatment out- 
lined, but does believe that the end result can be fairly well indicated in the majority of the cases during the first few months of the post- 
operative period. The danger of subjecting elderly patients, such as 
were found in his series, to surgical procedures, is well emphasized. 
The management of thirteen of the cases was outlined in detail. Smith- 
Petersen nails and Moore-3lount plates were used in the majority of cases. 
A Thompson nail was used in one case of transcervical fracture. In three 
of the cases outlined, all having transcervical fractures, two Smith- 
Petersen pins were used for internal fixation, ,fto give a mechanical hip". 
The author stated that double or triple fixation of hips has often been 
done, but that he has not seen a report of anyone using two Smith-Petersen 
pins. The use of two Smith-Petersen pins has given more satisfaction in 
his clinic than any other multiple fixation for transcervical fractures. 
Great stress is laid upon the necessity of reducing the operating time to 
a minimum, particularly in poor surgical risk patients. 
Boyd and George (26) discuss the results following treatment of fractures 
of the hip* In a series of 360 fractures of the neck of the femur, the mor- 
tality was 7 per cent. The mortality varied from 0 in the sixth decade, to 
1*2.9 per cent in the tenth decade. Bony union occurred in 8i*.7 per cent of 
the patients followed for one year or longer. In their experience, Pauwel*s 
type 3 fracture did not show a predisposition to non-union, as compared to 
type 2. The incidence of aseptic necrosis was higher in patients with non- 
union, than in those with union, approximately 60 per cent in the fomer 
and 33 per cent in the latter. Approximately one-third of the cases with 
bony union, followed for two years or longer, developed severe arthritic 
changes. The authors believe that the development of methods for the treat- 
ment of severe arthritic changes following union assume even more importance 
than the treatment of non-union. They conclude that although the statistics 
on this type of fracture appear discouraging, internal fixation is the treat- 
ment of choice for acute fractures of the neck of the femur, because the 
mortality is lower, the patient is more confortable, medical complications 
are less frequent, the percentage of senile psychosis is greatly reduced, 
the course of hospitalization is diminished, and the percentage of bony 
union is greater than with any other method. 
Urist (27) has prepared three papers concerned with the analysis of 
5>8 injuries of the hip joint which occurred in jeep accidents in World War 
II, in the European Theatre of Operations. The present paper deals frith 
fractures of the acetabulum, without dislocation. The 16 cases of fracture 
of the acetabulum presented in this paper fall into the following classifi- 
cations: (a) fractures of the rim of the acetabulum, 5 cases (b) central 
fracture, 8 cases (c) comminuted or bursting fractures disorganizing the 
entire joint cavity, 3 cases. In considering the traumatic lesion, certain 
anatomic considerations must be clearly understood. The weight bearing sur- 
face of the acetabulum consists of a lunate or horse-shoe-shaped platform 
of bone covered with articular cartilage. The anterior portion of the 
horse-shoe which is formed from the body of the pubis, is approximately 
half as wide as the superior portion. The anterior rim may be excised as 
in arthroplastic operations, without seriously altering the function of 
the joint, but the posterior rim is necessary for stability. The superior 
shelving portion is the thickest portion of the innominate bone, and is 
vital for the weight bearing function of the acetabulum. The status of 1U of the 16 patients in this group was followed. At the end of two years, 
11 of the military patients followed had no serious disability. Mary, 
however, complained of mild pain and clicking sensations in the joint, 
stiffness early in the morning, and discomfort from lifting heavy objects* 
Patients with displaced fractures of the supero-posterior rim of the ace- 
tabulum appeared to have more disability than those with anterior rim or 
central fracture. One patient with an unreduced fracture of the posterior 
rim had severe pain and some limitation of motion at the extremes of the 
normal range in all directions. One patient whose joint was accurately 
repaired at open operation, in contrast, had a normal hip. The three 
patients with extensive fractures of the acetabulum and destruction of the 
joint cavity, had ankylosis and complete disability two years after the 
injury. Fractures of the superior and posterior rims of the acetabulum 
of significant magnitude almost always resulted in some disability, but 
good function of the joint was obtained in one case after open reduction 
and accurate internal fixation. All evidence is to the effect that frac- 
tures of the pubic portion of the acetabulum are chiefly lesions of the 
anterior rim which is not essential to the function of the hip joint, 
while on the other hand, stellate or bursting fractures involve or distort 
the lunate, superior ard posterior articular cartilage of the acetabulum 
which is necessary for normal weight bearing. 
Intertrochanteric Fractures - Hammond and Cady (28) point out that 
since a large majority of the trochanteric fractures occur in patients 
over 60 years of age, it is only natural that serious associated diseases 
will greatly effect the prognosis in many cases. The occurrence of a 
serious femoral fracture with its attending shock, pain and complete dis- 
ability in a patient already debilitated by advanced age and systemic dis- 
ease is not infrequently sufficient to precipitate a fatal termination. 
However, efficient treatment of the fracture and prompt recognition and 
treatment of the associated diseases have resulted in a lower mortality 
in these cases. Close cooperation between the internist and the orthopedist 
should be productive of the best results. In recent years there has been 
an increasing number of trochanteric fractures treated by internal fixation, 
the advantages being early relief of pain, early mobilization and ambulation 
of the patient, decreased number of urinary, pulmonary and joint complica- 
tions, and a lowering of the mortality rate. Sixty cases of trochanteric 
fractures are analyzed from a medical standpbint, referring particularly 
to the incidence, type and management of serious co-existing disease and 
the effect of such existing disease on morbidity and mortality. In the 
opinion of the axithors, nothing is sacrificed by delaying operation until 
they start treatment towards the control of the co-existing disease, and 
this period of delay is time well spent as far as the patient*s prognosis 
is concerned. The authors found that their patients did better if they 
received a blood transfusion during the operation. The fractures usually 
were fixed with a Smith-Petersen nail with a Thornton plate attached. 
After closure of the wound the patient was placed in bed without any 
external splint. After operation, the patient was allowed bed freedom 
and change of position every two hours, with gradual change to the wheel- 
chair when the condition warranted. Crutch walking without weight bearing 
upon the involved extremity was allowed from two to three weeks after 
operation. Full weight bearing was not allowed until full union was 
demonstrated in the roentgenogram. Cleveland, Bosworth and Thompson (29) wrote on the management of the 
trochanteric fracture of the femur, describing the type of injury producing 
the fracture, outlining the factors modifying the mode of treatment, des- 
cribing the modes of treatment, and comparing the results of internal fixa- 
tion and traction. Patients with this fracture are an elderly group. Their 
average age is about 75 years, placing their age more than 12 years above 
that of the average of patients with intra-capsular fractures of the neck 
of the femur. Ninety per cent of the patients were women, a fact probably- 
explained by the less rugged bony structures and usually more pronounced 
atroohic osseous changes in women. The injury is generally trivial and 
the authors believe that most fractures of the type occur by dissolution 
of continuity of bony structures preceding the fall, and are not a result 
of the fall. They pointed out that perhaps the main contributing factor 
in such injuries lies in the elderly person*s inherent instability while 
erect and her slow reflex response. The authors state that trochanteric 
fractures may be roughly divided into three main classes, depending on the 
location of the major point of bony injury, namely paratrochanteric, inter- 
trochanteric, and subtrochanteric. They emphasize that the treatment of 
these fractures is not easy, and point out that the paratrochanteric frac- 
ture will tend to result in a final external rotation deformity, the subtro- 
chanteric fracture will tend to be difficult to control and finally may 
result in rotation deformity, shortening and angulation. In outlining the 
mode of treatment the authors discuss Buck*s extension, Russell balanced 
traction and the Whitman plaster spica. They do not favor the use of the 
latter, as a rule. With the gradual development of a method of attachment 
of a plate to the Smith-Petersen flange nail, internal fixation of trochan- 
teric fractures has become the treatment of choice provided the necessary 
equipment and a trained surgeon are available. Traction of the types prev- 
iously mentioned are suitable under circumstances where transportation is 
impossible and physical help unobtainable. The authors base their conclu- 
sion from a study of a series of 133 cases. One group of 38 patients treated 
by traction was compared with a second group of 95 patients treated by 
internal fixation. The final result was accurately known in the latter 
group. The study covered an eight and one-half year period. The great 
bulk of the fractures were paratrochanteric and generally comminuted (80$). 
The rest were subtrochanteric, paratrochanteric and the combination of the 
foregoing* Decision to attempt internal fixation as the method replacing 
balanced traction was made on a review of the records of the traction 
patients. A great many unsuspected complications appeared on their follow- 
up. Despite excellent nursing care, pressure sores on the sacrum and buttocks 
were the rule rather than the exception. Cystitis, bladder complications, 
residual stiff knees, hip contractures, permanent vascular changes, peroneal 
nerve palsies, muscle atrophy, senile psychoses, prolonged general inanition 
and debility and a high mortality were disclosed. The three flange nail 
with plate affixed with nut or bolt was found to lack stability at junction 
of the nail and plate, and after a trial was discarded. The Jewett nail 
was finally used with a few minor structural changes. Where nailing is 
properly done, no coxa vara or external rotation deformity will develop 
unless the nail breaks or pulls out of the bone. The nail most frequently 
used is angled at 130 degrees and is about three inches in length. After 
operation patients are replaced temporarily in traction pending application 
of a Thomas brace with pelvic band and knee lock. Continuance of such brace until solid union is obtained, is essential. Full weight bearing with 
the brace is neither necessary nor advisable. Such ambulation with minimal 
weight bearing can rapidly be permitted. Union rarely occurs before three 
months and sometimes is not complete up until seven months. The authors 
urge that early mobilization of the patient is admirable, but early full 
weight bearing may prove disastrous. There have been complications from 
this method of treatment, but far less frequent and much less devastating 
than those found in the conservatively treated group. In the conservative 
traction treatment group there was a mortality of 36$, while in the cases 
in which nailing was done there was a hospital mortality of only 12.6$. 
Eleven per cent of the patients treated by balanced traction developed 
senile psychoses and they were transferred permanently to mental institu- 
tions. Of patients treated by internal fixation, only 2.1$ experienced 
similar psychoses. As regards survival, 32$ of patients treated by trac- 
tion survived one year from the date of the fracture, while of those 
treated by internal fixation 72$ survived a year. By the end of the 
second year only 29$ of the traction treated patients were alive, with 
38$ of those treated by internal fixation survived. At the end of four 
years, only 13$ of the conservatively treated patients were alive, while 
30$ of those in whom nailing was done survived. In considering the time 
patients spent in the hospital, it was found that traction patients 
remained an average of ll* weeks while those with internal fixation stayed 
but 8 weeks. The authors now operate on and nail all intertrochanteric 
fractures because they have found that the patients survive despite adverse 
pre-operative opinion. 
Wahl (30) discusses the types of treatment which have been employed 
for intertrochanteric fractures and gives four case histories of patients 
in the age group of 80-89 years, treated by internal fixation with a 
Moore-Blade plate. He is of the opinion that the appliances which have 
been developed for use in fractures of the neck are not suitable for 
treatment of intertrochanteric fractures except those recently developed 
by Neufeld, Jewett and Moore. He considers these superior because they 
pass through the fracture line and anchor to the shaft of the femur with 
screws. He guards against the assumption that treatment of the intertro- 
chanteric fracture is much easier than that of the neck, emphasizing that 
intertrochanteric fractures produce more pain and shock than produced by 
fractures of the neck of the femur, on account of the frequency of severe 
bleeding following tear of the surrounding soft tissues. He concludes 
that the handling of these fractures in the aged is much more difficult 
than fracture of the neck of the femur. He points out that the problems 
of treatment are union without coxa vara, correction of the shortening 
and external rotation of the limb, avoidance of bed sores, pneumonia and 
thrombosis. He allows his patients out of bed one or two days after the 
operation and early ambulation with crutches in appropriate cases. 
Hammond (31) has presented a review of patients with U6 trochanteric 
fractures of the femur which he has treated by internal fixation. Like 
other authors he has come to the conclusion that internal fixation of 
trochanteric fractures is the method of choice, because of the advantages 
gained in providing early ambulation to these elderly patients. Fractures of the Neck of the Femur - Van Gorder (32) presents an 
excellent discussion of cases ot acute fractures of the neck of the femur. 
In the substance of the article are included paragraphs on the selection 
of patients for operation, the proper time for operating, the type of 
anesthesia, technique of reduction, technique of operation, post-operative 
care, and the prognosis. In summarizing the article the author reaches 
the following conclusions: (1) that age is no contra-indication to opera- 
tion; (2) that the optimum time for operation is within one week of the 
injury, and the earlier the better, all things being equal;(3) that accurate 
reduction of the fracture is of paramount importance, since the more accurate 
it is, the better the chances of union; the poorer the reduction the greater 
the chances of non-bunion ;(ly) that skeletal traction or a traction table is 
not necessary to reduce the fractures of the neck of the femur or to main- 
tain the reduction while they are being nailed;(5) that after manipulation 
and reduction of the fracture with the patient under anesthesia, manual 
holding of the fractured leg by an assistant is adequate;(6) that the most 
difficult fracture of the femoral neck to reduce and treat successfully is 
the sub-capital vertical type; this being so, treatment by nailing should 
be supplemented by bone grafting, or else some form of osteotomy should be 
performed;(7) that fixation material (nails, screws, pins, etc.) should be 
made of metals that produce no ionization in the tissues;(8) that arthro- 
tomy is not necessary for nailing of the majority of fractures of the femur; 
(9) that the operation can be performed with little trauma or shock;(10) 
that the proper position for the Smith-Petersen nail is along the lower 
half of the femoral neck, its sharp end centering in the proximal portion 
of the head of the femur in both antero-posterior and lateral planes;(11) 
that the lateral roentgenogram is indispensable in determining the reduction 
of the fracture and the placement of the nail;(12) that it is rarely necessary 
to drive the guide wires across the joint line into the acetabulum in order 
to control location of the femoral head while nailing;(13) that if complex 
multiple wires or pins are used for internal fixation of the fracture some 
form of retention apparatus such as a nut inserted on the ends of the wires 
must be employed in order to prevent them from wandering out of their posi- 
tionally) that patients can be gotten out of bed on the day of operation or 
the day following, but that this procedure is not necessary as a rule, is 
often ill advised and should be employed only in exceptional instances;(l£) 
that the prognosis of fractures of the neck of the femur depends to a large 
extent on their location, their obliquity, and the adequacy of nursing care 
received ;(16) that according to the most reliable reports and literature, 
internal fixation methods of treating fractures of the neck of the femur 
result in a higher percentage of bony union and a much lower mortality than 
do methods involving external splinting and traction. 
Fitzgerald (33) discusses two anatomical features which may lead to 
non-union in cases of fracture of the neck of the femur. The first is that 
the tendon of the obturator externus muscle which lies very close to the 
femoral neck and actually grooves its under surface, might slip in between 
the bone ends either at the time of fracture with the lower fragment 
moved upward, or during the usual Leadbetter method of reduction when the 
hip is forcibly internally rotated and abducted. In addition, he points 
out that when the femur is forcibly internally rotated in an effort to 
reduce the fracture, a wide transverse gap develops on the posterior sur- 
face of the neck. A nail inserted after forced internal rotation, therefore. would have a grip in the outer fragment and in the head of the bone, but 
would be uncovered posteriorly while traversing this area* After having 
found that a very large number of cases had failed to unite when operated 
upon after forced internal rotation, the author decided to accept some 
external rotation deformity and has found that the percentage of success 
has been much higher* In discussing the types of fractures and their treat- 
ment, the author divides the cases into the impacted and the non-impacted 
fractures* He further divides the former into coxa valga with impaction 
and coxa vara with impaction. In the cases of coxa valga with impaction 
the author immobilizes the hip in a closely fitting plaster spica and allows 
it to remain for two months, the patient being allowed to walk after a few 
days. In the cases of coxa vara with impaction which he manages conserva- 
tively, the patient is kept in bed on a Braun splint with 10 pounds tract- 
ion for three months and is then allowed to get up. In the impacted cases 
operated upon, the nailing is done ’without any attempt at reduction of any 
kind. For the treatment of non-impacted fractures, the author describes in 
detail two operative procedures, nailing and a modified form of Leadbetter’s 
osteotomy. 
Waspe (3li) reports a case of sub-capital fracture of the neck of the 
feraurl ?He patient was first seen in November 19i*7 with a swelling on the 
medial side of the upper part of the thigh following a blow in the region 
of the right hip. The patient stated that he had received an injury in 
this situation in 19l*X. During the discussion it was agreed that this was 
an old abduction transcervical fracture of the neck of the femur, the type 
which usually unites in spite of lack of immobilization. 
Martin (35) reviews 7U cases of fractures of the hip treated in the 
previous two years. The Moore plate was used for intertrochanteric frac- 
tures and the Smith-Petersen nail or Godoy-Moreira screw for high fractures. 
The screws gave excellent fixation, but there was difficulty in engaging the 
large thread with the hard bone near the acetabular surface. Many failures 
with the Smith-Petersen nail were due to insufficient engagement of the head. 
Direct fluoroscopy was employed. 
Caniza (36) is of the opiniom that many anatomic fractures which are 
classified as impacted are really not impactions but rather an overlapping 
of portions of the neck due to the displacement of the two fragments. He 
states that this can easily be verified by taking another X-ray with the 
limb in the abducted position. In his opinion, a real impaction is a part- 
ial sub-capital fracture in which the head is depressed somewhat backward 
as in epiphyseal fractures. Caniza prefers the cannulated Smith-Petersen 
nail which is threaded on a Kirschner wire and driven home. He points out, 
however that the operation should not be taken lightly by the uninitiated. 
George (37) reviewed 300 cases of central fracture of the neck of the 
femur treated at the Campbell Clinic. Only type 2 and type 3 fractures 
according to the classification of Pauwel, are included in the study. Of 
the group of 300 cases, 252 were type 2 fracture (81$) and 1*8 were type 
3 fractures (16$). Seventy-eight per cent of the patients were 60 years 
of age and over. Eighty-two per cent of the patients were women and 18$ 
were men. The author explains the striking difference between the incidence 
i?o of the two sexes by assuming that since elderly men lead a more active life 
than elderly women, there is not as much osteoporosis of the bones of the 
men# He also explained that the preponderance of women may also be due to 
their wider pelves, with a resulting genu valgum# The overall mortality 
rate was 9*3$« Of the 300 cases reviewed, only 1*7$ had adequate follow-up 
for over one year# Concerning the 1*7$ (1U1 cases), bony union occurred in 
86|$ and non-union in 13 J$. Ninety-three and three tenths per cent of the 
1*5 cases under 60 years developed bony union. There were no non-unions of 
the 11 cases under 1*0 years of age# In the 96 cases over 60 years of age, 
the percentage of union was 83.3$. There were 10.3$ non-unions in type 3 
fractures, and li*$ in type 2 fractures. In reviewing these cases the im- 
pression was gained that accurate reduction and adequate nailing of the 
fracture fragments influences union. As regards aseptic necrosis, it is 
found that in the group of 122 unions there were 1*1 cases (33$) which 
showed aseptic necrosis at some time during the follow-up. No relation- 
ship between age and aseptic necrosis was found. In 19 cases it was dis- 
cernible in 9-15 months, in 11 cases in 15-27 months, and in 11 cases 
after 2? months. On this basis it was concluded that the greatest number 
of cases begin to show changes in the head in about one year, and the length 
of time up to two and one-half years gives no assurance that aseptic necro- 
sis will not develop. In the non-unions, approximately 60$ of the cases 
showed aseptic necrosis of the femoral head. Nineteen per cent of the 
hips (23) showed moderate arthritic changes in the head, and 11*.6$ (18) 
showed severe arthritic changes. The time of appearance of arthritic 
changes seems to follow a time of appearance of aseptic necrosis from sev- 
eral months to a year. The author concludes that even though the statistics 
present a rather dreary outlook for internal fixation this method is much 
superior to the Whitman abduction method. As to optimal time for operation, 
the author believes that it is highly advantageous to the patient to operate 
within the first 1*8 hours. 
Neer and McLaughlin (38) furnish a follow-up report of 130 patients 
treated with internal fixation with a Smith-Petersen nail. The cases are 
segregated into three categories according to the classification described 
by Pauwel, type 1, valgus; type 2 mid-neck; type 3* oblique sub-capital. 
In the group there were 26 valgus with average age of 59, 57 mid-neck with 
average age of 66, 1*7 sub-capital with average age of 66. As regards the 
management, every hip fracture was considered an acute emergency demanding 
early treatment designed to minimize the period of pain and bed stay. 
Eighty per cent of the patients were operated upon within 6 hours of admiss- 
ion. Impacted valgus lesions were nailed without reduction or visualization 
of fracture. All displaced fractures were reduced prior to fixation. Sub- 
capital oblique fractures were the most difficult to reduce and frequently 
could not be reduced adequately with manipulation alone. Following opera- 
tion 65$ of all patients were allowed out of bed within 2h hours. Those 
physically able to use crutches commenced ambulation without weight bear- 
ing in a walker about the fourth post-operative day, and were promoted to 
crutches as rapidly as possible. The mortality in this series is outlined 
as follows; operative 2$, related 2$, unrelated 8$. The results in 
each type of fracture are discussed in detail. The over-all results are 
tabulated as follows:- total mortality 10.7$, non-union 21.9$, aseptic 
necrosis 1*2$, in the open cases. In the closed, the mortality was 9.7$, non-union 16.1$ and aseptic necrosis 5h%» The authors conclude (1) that 
the best time for reduction and fixation of the hip fracture is immediately 
(2) good treatment for impacted valgus fractures of the femoral neck is 
internal fixation and avoidance of bed stay (3) open reduction, properly 
done, is surer, shorter, but more dangerous than closed reduction and 
blind nailing (i*) open reduction does not increase the incidence of sub- 
sequent aseptic necrosis. 
Ellis (39) and his co-authors discuss their experiences and results 
obtained in treatment of 30 cases of fractures of the neck of the femur 
and the trochanteric region. They believe that internal fixation of frac- 
tures of the femoral neck, using the closed method of treatment is the one 
of choice* 
Gallagher (1*0) presents a review of 77 consecutive fresh fractures 
of the neck of the femur treated at Jackson clinic during the years 1936- 
191*6 inclusive. In this series, 17$ were under 60 years of age, 23$ 
between 60-70 years, £9$ between 70-90 years and one over 90 years. 
Eighty-eight per cent were females, twelve per cent were males. Thirty 
per cent of the patients had impacted fractures and all made uneventful 
recoveries except one who submitted to internal fixation and subsequently 
developed absorption at the fracture site and aseptic necrosis of the 
head. There were 3 deaths in this group from 2-9 years following injury* 
Treatment of those with impaction was conservative, consisting of bed rest, 
traction with from l*-£ pounds for one month to six weeks and then a wheel- 
chair and partial weight bearing with crutches. Full weight bearing was 
permitted at 3-6 months. No disrupted impactions or other complications 
developed during the hospitalization, largely due to the excellent nursing 
care. Of the 55 displaced fractures of the neck, sub-capital, transcervical 
and basal, £2 were treated with internal fixation with a Smith-Petersen 3 
flange nail under spinal anesthesia. The over all mortality in the dis- 
placed group numbered 22, or 1*0$. The deaths occurred anywhere from 3 
months to 9 years postoperatively. The principles generally adhered to 
were (1) antero-posterior and lateral x-ray examination on admission,(2) 
immediate traction,(3) evaluation of physical condition with supportive 
therapy, (1*) accurate reduction using modified Leadbetter technique,(5) 
lateral nailing with Smith-Petersen nail,(6) impaction,(7) leg traction 
for one week,(8) early ambulation and discharge from the hospital in three 
weeks using crutches,(9) discard crutches at three monthsf(10) follow-up 
x-rays at 3-1* month intervals for 2 years. In this group there were 6 
non-unions or ll.£$; 28, or 53»8$ showed aseptic necrosis; and 35* or 
67.3$ of these patients had degenerative arthritic changes of various 
degrees characterized on x-ray by lipping, diminution of joint space, 
coarseness of traoeculation, thinning and eburnation of the articular 
cortices. The nails were removed in 18 cases at various intervals after 
one year after aseptic necrosis had occurred; in 10 cases the nail was 
loose and partially extruded and the cannulated portions filled with 
necrotic debris on microscopic examination. The author concludes that 
the incidence of aseptic necrosis and degenerative arthritic changes is 
alarmingly high in this series. He attributes these conplications to 
(1) too early weight bearing and (2) internal fixation by lateral nailing 
adds a certain amount of damage to the already acutely impaired circulation. He believes that the Smith-Petersen nail has stood the test of time# 
Perhaps with the addition of a cancellous bone graft or some other means 
of promoting osteogenesis, and delay in full weight bearing for a year or 
so, a more satisfactory program will be established. 
Fractures of the Shaft of the Femur 
TTiltberger, IftifcReTI, and"Hedrick (1*1) discuss fracture of the femoral 
shaft complicated by hip dislocation and report a case successfully reduced 
by the closed method. The authors emphasize the rarity of the condition 
and state that over a period of 31 years at the Henry Ford Hospital, only 
four cases have been seen in a total of 1*96,000 patients. This would aver- 
age about one case in 125,000. In the case being reported, the patient 
was a white male 35 years old who was struck from behind while kneeling 
by a large girder which had slipped from an overhead crane. Roentgenogram 
had disclosed an oblique fracture of the upper third of the right femur 
and a complete posterior dislocation of the hip joint. An unsuccessful 
attempt at closed reduction of the dislocated hip was made with the Bigelow 
and Ellis procedure. Thereafter a reduction-retention apparatus with 
threaded pins was used, with the pins placed approximately four inches 
apart into the lateral aspect of the trochanter of the left femur. After 
two additional unsuccessful attempts were made at reduction, a two foot 
length of gas pipe was threaded across the bar of the reduction apparatus, 
paralleling the distal fragment and being attached by the apparatus to the 
proximal fragment. With the gas pipe lever a successful reduction was 
carried out by means of the Bigelow maneuver. The patient was then returned 
to the ward where he was placed in skeletal traction. Roentgenograms taken 
the next day showed the head of the femur to be in the acetabulum and the 
fracture to be in almost anatomical position and excellent alignment. Six 
months later it was found, after testing the patient clinically and taking 
roentgenograms, that he had non-union at the fracture site and that the 
proximal fracture of the femur cast a shadow of increased density. The 
authors believe the latter condition to be excessive stripping of the 
periosteum at the time that the dislocation took place. An open reduction 
was performed and a vitallium plate and massive onlay bone graft from the 
tibia was placed across the fracture site. The post-operative course was 
uneventful and the fracture healed, three months later. 
Humphries (1*2) discusses the general subject of fractures of the 
femur, based on his experiences in the treatment of 33 consecutive cases; 
32 fractures of the shaft and one of the neck. In discussing the treat- 
ment of trochanteric fractures, the author states that whenever possible 
the fracture should be nailed, and the nail introduced at a much lower 
level and in a more vertical direction than for a transcervical fracture. 
If the fracture is comminuted, leg traction is preferred to nailing. In 
the treatment of abduction transcervical fractures, impaction of the frag- 
ments is not interfered with. The limb is immobilized in a short spica 
plaster cast which includes the pelvis and extends to just above the knee 
on the affected side, with the limb in a position of extension, slight 
abduction, and no rotation. Internal fixation with the Smith-Petersen 
nail is preferred in the abduction transcervical fractures. Osteotomy is 
believed to be indicated in the treatment of ununited fractures of the 
neck in which it is not worthwhile attempting repair of the fracture 
owing to destruction of the blood supply of the head, arthritis of the 
hip joint, deformity of the joint or shortening of the neck. Stuck and Grebe (i*3) report on a survey of 12i* consecutive fractures 
of the shaft of thefemur observed over a period of 15 months in an 
Army hospital. In this group of 12h fractures, 25 were in the upper 
third, 8ii in the middle third, and If? in the lower third. Only 28 of 
these patients received their entire treatment at the hospital where 
the authors worked. Eighty-four patients received their fractures from 
automobile or other vehicle accidents, 19 were due to explosions or to 
the effects of high velocity missies, and 13 fractures were due to falls 
from a height, including a parachute jump. The remainder were due to 
miscellaneous causes, airplane crashes, blows from an airplane propeller 
or pathological fractures. Eighty-six were simple fractures, and 38 were 
compound. Thirty-two patients, or more than one quarter of the series, 
suffered serious complicating injuries. As regards the treatment, some 
form of skeletal traction was used in 91 cases. In 20 cases a Kirschner 
wire or Steinmann pin was placed in the lower end of the femur above the 
knee, and in 71 cases the wire or pin was placed through the upper end 
of the tibia. No ill effects were observed from traction in the upper 
end of the tibia, and the conclusion is drawn that traction through the 
upper end of the tibia does not endanger knee motion as much as a pin 
through the lower end of the femur which may produce adhesions of the 
capsule of the knee joint. Eighty operations were performed and screws 
were used in 33 cases, bone grafts and screws in 16 cases, plates and 
grafts combined in 30 cases, and screws alone in 1. Sometimes several 
different operative methods of treatment were combined in one case. The 
principal complications were; failure to reduce fracture with traction - 
35 cases; refracture or secondary fracture - 21 cases; delayed or limited 
union - 13 cases; non-union of fracture - 12 cases; limitation of knee 
motion - 12 cases; raal-union of fracture - 11 cases; infection due to 
injury - 10 cases; infection from open operation - 8 cases; shortening lw 
or more - 7 cases; non-union of fracture after open reduction - 6 cases; 
renal calculi - 3 cases; thrombophlebitis - 1 case; delayed union or 
limited union was the most frequent complication encountered. The authors 
believe that an earlier reinforcement bone graft hastens recovery and pre- 
vented secondary refractures. Ununited fractures of the shaft of the 
femur were treated with multiple iliac bone grafts. 
Fractures of the Patella; - Coleman (UW adds two case reports of 
recurrent osteochondral fractures of the patella to the literature. 
This author states the fracture occurs in two frontal sections with an 
articular portion shearing off and remaining displaced while the anterior 
portion reduces itself. He states the mechanism of injury is produced 
by the patella sliding laterally over the lateral femoral condyle, and in 
so doing scoring the articular surface of the patella and condyle. The 
medial border of the dislocated patella is caught by the edge of the 
lateral condyle when the quadriceps contracts, causing considerable tan- 
gential force which is applied, shearing off a portion of the articular 
cartilage of the patella usually with a thin layer of underlying bone. 
He feels that these fractures should be recognized early, loose bodies 
removed, the defects in the articular surfaces smoothed off, or the pat- 
ella removed if intensively involved. He states plication of the capsule 
on the medial side is recommended in order to prevent recurrence of the 
injury. Michele and Krueger (k5) report a method of wiring used in 32 of 
2J|7 cases of fresh fractures of the patella over a five year period from 
19U2 - 19h7. The election of wiring cases had one pre-requisite in their 
study, namely the main fragment had to show one inch or more separation# 
Excellent diagrams are included to show in detail the method of wiring. 
They stated that the results of this method of treatment reveal (1) smooth 
and sturdy closure of the fracture,(2) reduction of complications follow- 
ing such fractures, as well as greater ranges of motion when some limit- 
ation of motion was present, (3) marked reduction of the number of days 
hospitalized as well as of convalescent days, early ambulation and nurs- 
ing care and (U) the final healed patella more nearly simulated a normal 
patella than following other methods# 
Fractures of the Tibia: - Loomis (1*6) reports a series of 20 cases 
of open reduction of oblique or spiral ffactures of the tibia with in- 
sertion of one or more vitallium screws across the fracture site which 
in his hands is a simple method of restoring length and minimizing 
delayed union by hairline reduction# He states that this type of frac- 
ture is accompanied by (1) shortening due to forces or muscle pull upon 
the fracture and (2) delayed union caused by poor blood supply to the 
distal fragment especially in the -distal third of the tibia# He outlines 
recognized surgical and orthopaedic principles and in addition recommends 
application of the head of the screw on the medial side of the tibia for 
easy removal at a later date, a high leg cast after operation, and a 
Steinmann pin through the upper tibia incorporated in the cast in obese 
patients to reduce rotation strain# He feels that hairline reduction 
may be misinterpreted as union, encouraging premature cast removal and 
too early weight bearing# 
May (U7) explains in anatomical detail the cause of the high incidence 
of non-union in double fractures of the shaft of the tibia# He states 
that it is caused by disturbance of the interosseous circulation follow- 
ing such fractures, and particularly in double fractures with a segment 
deprived of its blood supply because of the few anastomoses unless the 
segment contains the nutrient vessels. He feels in segmental fractures 
the best treatment is complete and prolonged immobilization of the limb 
in a skin tight plaster cast to permit ingrowth of vessels from the peri- 
pheral fragments, and states if non-union does occur the best treatment 
is by bone graft, long enough to bridge both fracture sites# In order 
to avoid weakening the other leg by taking a long massive graft from the 
tibia, this author advises the use of a fibular graft from the same side# 
He prefers transfer of the fibula to the tibia in stages, and recommends 
fusion of the upper tibio-fibular joint in the first stage and osteotomy 
of the lower part of the fibula and fusion of this part to the tibia in 
a second stage# By this method he feels that the fibula does not become 
separated from its blood supply# 
Dislocation of the Head of the Fibula: - Vitt (I4.6) reports four 
cases of anterior dislocation of the head of the fibula from parachute 
landing falls. He states that the condition occurs in a twisting lat- 
eral fall at the time of striking the ground, and is associated with 
inversion ankle strain. He feels it is related to the relaxation of 
the fibular collateral ligament and the tendon of the biceps femoris. because paratroopers are taught to land with the knees flexed and to- 
gether, He states that the symptoms are a feeling of the knee being 
"out of Joint", limitation of extension from 170-160 degrees and 10-20 
degrees limitation of flexion. In his series there was no sign of 
peroneal nerve involvement. He reduces the dislocation under pentothal 
by inverting the ankle, flexing the knee and direct posterior pressure 
over the head. 
Fracture of the Fibula: - Burrows (U9) reports five cases of fatigue 
fractures of the fibula together with a review of the literature on this 
subject, . He feels that the stress of muscular action is emphasized by 
fracture of the fibula, a non-weight bearing bone, and in his series 
there is no predominance of the site, age, sex, or occupation. He calls 
attention to the predominance of two groups of patients in whom this con- 
dition may occur (1) young male runners or skaters and (2) women of mid- 
dle age or over who have much to do on their feet. He feels that freedom 
of movement, in spite of tenderness, helps to distinguish this group from 
sprain, and re-emphasizes that in early suspected cases films should be 
repeated in three weeks, for x-rays at time of the first signs and symptoms 
may be negative, with a fracture line appearing after rarefaction at the 
end of the second or third week. He treats this condition with an elastic 
adhesive bandage from the metatarsal heads to the upper calf, and notices 
the pain diminishes or disappears within a week although tenderness may 
remain as long as 8-16 weeks. 
Fractures of the Ankle: - Lange (£0) presents an analytic historical 
survey of ankle fractures completely covering the subject from Hippocrates 
to modem times, and concludes: (1) the exact genesis of most fractures 
of the ankle is still unknown ,(2) the problem of relationship between the 
marginal tibial fractures and the malleolar fractures, and between the 
former and rupture or detachment of the syndesmotic ligaments has not 
been solved ,(3) a sure knowledge of rupture or detachment of the ligaments 
of the syndesmosis and various types of ankle fractures has not been reached, 
(U) the criteria of rupture or detachment of syndesmotic ligaments are un- 
certain t(5>) the classification of malleolar fractures is almost chaotic 
and ,(6) no attempts have been made to reduce malleolar fractures in con- 
formity with their actual nature* 
Winkler (£l) classifies fractures about the ankle Joint as fractures 
with dislocation or without dislocation. He states it is always wise to 
test the ankle for tear of capsule or ligaments at the site of the frac- 
ture by-grasping the foot as a whole and attempting to push it toward the 
fracture zone. He states no twisting should be done or the test is of no 
value, and he feels that if the ligament or capsule on the side opposite 
the fracture has been tom the patient immediately winces or feels pain 
in the fracture, and that such a positive response to the test should re- 
sult in immobilization of the ankle in plaster longer than if the test is 
negative. He feels that cases with proven ligamentous tears should be 
immobilized at least six weeks. 
Kaye (£2) presents a concise carefully written review of fractures 
about the ankle Joint in children and in adults with excellent discussion 
of anatomy and physiology primarily favoring closed reduction. However, 
he feels that open reduction should be done within 1*8 hours after injury if manipulation can not reduce or maintain the reduction. 
Callahan (53) describes fractures of the internal malleolus as 
simple or complex, the latter term recently popularized by Conwell as 
designating simple fractures complicated by blebs or lacerations of the 
skin. His article concerns only fractures in which reduction is un- 
successful and those in which conservative treatment is necessarily 
prolonged because of skin complications. He feels that fibers of the 
transverse ligament frequently complicate the problem by preventing 
complete manual reduction by stretching between the fragments or tendons 
and that this ligament can be removed only by surgery. He emphasizes 
the danger of accepting as good enough reduction one which is neither 
adequate nor anatomic, and feels that accurate reduction is important 
because failure promotes painful ankles and feet, altered weight bearing 
and arthritic changes. He warns against procrastination in surgical treat- 
ment of fresh fractures in which initial attempt at reduction is unsuccess- 
ful. He feels that the longer surgery is postponed, the more difficult it 
is to perform and the more uncertain the end result. 
Fractures of the Foot: - Otten and Mumford (5k) report novocaine 
injection treatment of metatarsal fractures used in 62 cases. In their 
hands the disability was an average of 11,6 days in 35 cases injected 
with novocaine, U7»3 days in Ik cases immobilized in plaster of paris, 
32 days in 5 cases injected and immobilized in plaster of paris, and 
22,6 days in 3 cases injected and strapped. They infiltrate the fracture 
line with 10 cc, of 2% novocaine and make an attempt to gain normal anat- 
omical reposition of fragments. They feel that it is essential that any 
plantar angle be corrected, but lateral displacement is not objectionable. 
The patient is advised to use crutches but to have weight bearing to some 
extent to the point of pain. The authors use no immobilization or splint- 
ing either with adhesive or plaster of paris, and the patient returns to 
work when pain upon full weight bearing is such that work can be tolerated. 
Palmer (55) describes fractures of the calcaneus as a linear fracture 
of one’“oT~three types, avulsion, compression or shearing, and describes 
in detail with excellent drawings the anatomy underlying the types. He 
feels that the shearing type of fracture is intra-articular and comprises 
the largest group, at least 50% of all fractures of the calcaneus, and he 
found that most patients who sustained this type fracture had a permanent 
disability of 25 to 33-1/3$* In performing arthrodesis of the sub-talar 
joint for this condition, the author found that a ledge was created in 
the joint which sometimes reached the height of 10 mm, and feels that this 
ledge is due to compression of the substance of the calcaneus itself. He 
presents the treatment divided into three steps; (1) reduction of the entire 
lateral block of the shearing fracture, (2) reduction of the secondary 
compression fracture involving the articular surface and (3) filling the 
bony defects which result from elevation of the articular fragment from 
the normal position. The author puts a graft from the crest of the ilium 
into the defect left by the compression after reduction. He uses a short 
leg cast post-operatively, allovfs the patient to walk 2-k days after the 
operation with crutches, and after 12 weeks replaces the plaster by a 
zinc-paste stocking and strong shoe with longitudinal arch support. He reports 23 cases vdth all patients back at previous work from I;-8 months 
after the operation, with painless pronation and supination in the sub- 
talar joint of 15-30 degrees. 
Fracture of the Os Galcis: - Miller (56) presents an overall review 
of the~lnodSrnT3?ea:EnenF^?~Tractures~^?~the os calcis not including the 
methods presented by Ivar Palmer, and calls attention to the fact that 
most patients with fractures of the os calcis have swelling of the foot 
after the fracture has united. This is worse in older patients or where 
there has been gross injury. He treats this by contrast bathing, by reg- 
ulated exercises, and by a detachable pressure bandage. He feels that some 
permanent broadening of the heel may remain due to soft tissue fibrosis 
and feels that stiffness is usually due to post-traumatic adhesions in 
the tarsus and resultant lack of mobility in the foot. He recommends 
mild manipulation followed by active and energetic exercise. 
Medullary Nailing: - Wiggins and Lewis (57) of the United States 
Navy Feport their experiences in 6 cases of fracture of the femur in 
which intramedullary nails were used to supply the internal fixation. 
The intramedullary nail utilized in the cases reported were 18-8 SMO 
stainless steel, 15" in length, 5/l6" or 3/8" outside diameter, and .35" 
in thickness. The nails were flattened in order to accommodate the 
handling of the guide. The open type of operation was employed in intro- 
duction of the nails in each case. In the first two cases of the series 
no external immobilization was employed during the post-operative period, 
with deferment of weight bearing until clinical and roentgenologic union 
had occurred. The complication of bending of the nail in the third case 
led the authors to the use of post-operative skeletal traction immobili- 
zation in the remainder of the series. The cases are described in detail. 
The authors offer the following comments and conclusions: The intramedul- 
lary nail may be substituted for other methods of fixation when open red- 
uction is necessary; intramedullary fixation is not indicated except in 
femoral fractures, and only in those in which closed reduction has failed 
or which for other reasons must be openly reduced. The two serious compli- 
cations which occurred in this series were re-fractures and bending of the 
nail. No post-operative infections occurred. The authors are of the opin- 
ion that the American manufactured rolled sheet stainless steel available 
to them is not strong enough to provide satisfactory fixation in all individ- 
uals. 
Westerborn (58) reported on his experiences in 100 cases of marrow- 
nailing of recent fractures, pseudarthrosis and bone plastics. The author 
employs either the closed or open method after reposition, as the situation 
demands. The nails used in his cases were manufactured by Instru- 
ment Company in Gothenburg, Sweden. The nails were of rustless steel. The 
first nails were not sufficiently strong and were bent at the time of in- 
sertion or later through the strain of the fracture. The author points out 
that the hardness of the steel must be just right because if they are manu- 
factured of too hard steel they are not flexible enough to conform to the 
shape of the medullary cavity when being introduced. The author believes 
that absolutely firm fixation is necessary for the proper healing of the 
fracture. For this, he points out, one must choose a nail which fits well into the marrow cavity and ascertain that the latter is a fairly even 
width. This is the case in the cavity of the femur and to a certain 
degree in the radius and ulna, but not in the tibia and humerus. Thus, 
the best results are obtained in the nailing of femoral fractures. The 
nail must be wide enough so that it establishes firm contact with the 
wall of the marrow cavity, mainly in order to prevent rotation between 
the fragments. The size of the nail can be chosen by estimating the 
size of the marrow cavity in the roentgenogram. He states that, accord- 
ing to Fischer, with a focal distance of 75 cm, the marrow cavity is really 
1 ram, smaller than it appears to be on the roentgenogram. The conditions 
are not so favorable in the tibia as they are in the femur, for here the 
cavity is narrowest in the middle. Consequently, it is easy to obtain 
firm fixation of the fracture situated in or about the middle of the tibia, 
but not of one situated more distally or proximally. The advantages of 
medullary nailing are great in these cases because the patients can be 
allowed up early and can soon begin to bear weight on their legs, avoid- 
ing stiffness in the joints and muscle atrophy. Another great advantage 
is that the patients are immediately rid of pain. It is also maintained 
by Kuntscher and others that the nailing accelerates the formation of 
callus, thus considerably reducing the time before the patient is able 
to resume his normal occupation. The author makes the point that when 
the nail can only be inserted 3 or i* cm, in the distal fragment it is 
necessary to apply a plaster encasement for some weeks, and early weight 
bearing is out of the question. He also emphasizes that no definite agree- 
ment has been reached about the indication for medullary nailing, pointing 
out that while some surgeons have narrow indications, others have fairly 
wide ones. In considering the risks involved in this type of operation, 
the author is of the opinion that marrow destruction, fat embolism, and 
osteomyelitis are to be feared most. He says that experience has already 
shown that the damage which the nail causes to the bone marrow is of 
little practical significance. He recommends, however, that the nail be 
removed when full consolidation is established. As regards fat embolism, 
the author cites two deaths reported by Kuntscher and Habler, but since 
detailed information is lacking, it is not known whether the fat embolism 
occurred as a result of the fracture or of the nailing. According to 
reports in open fractures extensive osteonjyelitis generally does not 
develop, but only restricted osteitis with local sequestration, mainly 
due to the fact that pus in the marrow cavity is led off along the nail. 
Thus, according to Kuntscher, Bbhler, and others, there is never any en- 
closure of pus in the cavity with rising pressure which is generally 
thought to be the cause of extending osteomyelitis. The author is also 
fond of medullary nailing in the cases of pseudarthrosis, having nailed 
21* cases of pseudarthrosis up to the time of the writing of the paper. 
In a follow-up of these cases bone healing was satisfactory in all but 
three cases where inflanmatlon recurred after operation. The author goes 
on to advise that in order to hasten bone healing the marrow nailing may 
be combined with other operations such as bone transplantation, either in 
the form of chips or with a larger piece of bone. The method is also use- 
ful in cases requiring bone lengthening or bone shortening to cover a 
deficiency of bone. The author includes 15 case histories to illustrate 
the points cited in the review. Hedri (£9) reports on 82 cases of intramedullary nailing of 
fractures of the femur, discussing the pathology, complications, indi- 
cations and technique* The author states that, judging from cases on 
record, no sequestration and no fistulae develop if there is no infect- 
ion* Undisturbed and smooth development of callus has been proved by 
animal experiments, and by surgical results in 82 cases* X-ray control 
films demonstrate that ossification of the ends of the fragments is per- 
fect. In his opinion the fracture itself, by its violence, causes worse 
medullary destruction than does this method of nailing* None of the 82 
cases in the author’s practice died of fat embolism* The effect of the 
operation on the marrow as a blood generating organ was found to be as 
follows; red blood cells increased to between 10$ and 30$ with a corres- 
ponding rise in hemoglobin; in many cases the thrombocytes and reticu- 
locytes increased by £0$; there were no noticeable changes in the leukocyte 
counts; the qualitative blood count showed juvenile forms, with a lively 
increase in eosinophiles, in some cases as much as 8$ to 10$. He concludes 
that medullary nailing is apt to stimulate the blood generating activity 
of the marrow. The most serious complication was infection* Suppuration 
occurred in i; cases (6$). All these cases with suppuration were old com- 
pound fractures with osteomyelitis and mal-union, or cases healed with a 
false joint* None of the infected cases had the advantage of penicillin* 
In discussing the indications for intramedullary nailing the author in- 
cludes: (1) badly consolidated fractures of the femur; (2) those healed 
with a false joint; (3) such nevf fractures of the femur which cannot be 
dealt with by conservative means; and (li) where open reduction with inter- 
nal fixation is indicated* Regarding the question of ’’open nailing” versus 
’’closed nailing”, the author has adopted the open method because old frac- 
tures such as badly consolidated fractures and non-union have to be laid 
open anyway* The open method is also applied to fresh cases because the 
nailing is much less difficult than by the closed technique* 
Fraenkel (60) records his observations in intramedullary nailing of 
fractures* The following details were extracted from a careful analysis 
of 155 cases operated on at Kiel from January 1, 19UU to Mayl,19U6* Femurs - 
subtrochanteric fractures are very satisfactorily controlled with a sliort 
special nail. In the shaft a guide pin is usually employed and it or the 
nail is of help in manipulating the upper fragment* In supracondylar 
fractures the nail is of great value in obviating angulation, but additional 
immobilization is required because of the width of the marrow cavity* Of 
35 simple fractures, 27 were stable. The others required additional immo- 
bilization, but angulation was absolutely prevented. In the stable cases, 
the patients started walking in 7—U2 days. No nails were removed before 
U months. Of 7 compound fractures, 3 were stable without additional immo- 
bilization. All united and only 1 case, with gross loss of soft tissue, 
had loss of function. Four pathological fractures were nailed and irrad- 
iated and 2 osteotomies were nailed with excellent union* Tibia: - Owing 
to the hourglass shape of the marrow cavity, a special double nail is in- 
serted from the region of the tuberosity or of the medial malleolus. The 
first nail carries a wedge which forces away from it the following second 
nail, thus securing the lower end firmly* Of k6 simple fractures all those 
put up with the double nail were stable; but 10 nailed with a single nail 
because of multiple fractures which the double nail could not pass, or for 
other reasons, required additional plaster. Even in these cases the position 
ISO was far better than could have been otherwise achieved* No nails were 
removed before 3 months, and there was difficulty in extraction in 2 cases. 
Of 1£ compound fractures, U4. were stable. Humerus:- This can be nailed 
with ease from below or above* The early and full function of the arm 
and hand is remarkable* Ten closed fractures were all stable and received 
good union with good function* Nailing of 2 pseudarthroses with freshening 
led to good union, Radius and Ulna:- The radius is nailed from the lower 
end and the ulna from the upper end. The stability of this method of fix- 
ation offers great advantages here but reduction may be difficult* In 16 
fractures open reduction had to be used in 6 cases* All united well except 
one worker who started heavy work U weeks after injury without medical con- 
sent* The nail was broken and a pseudartfcrosis developed in the ulna* 
This united after extraction of the nail, freshening and renailing* Nails 
were left in at least 3 months. The author’s impression is that the advan- 
tages derived from early and anatomical union, and from the full joint and 
muscle function, preserved throughout, outweigh the disadvantages which 
are mainly the necessity for a moderate amount of apparatus and for screen- 
ing* The dangers of sepsis and fat embolism appear to be largely theoret- 
ical and there is ample evidence that the nails have no adverse effects 
on the bone marrow. 
Devices for External Fixation:- Spriggs (61) discusses the employ- 
ment of the Haynes splint treatment in fractures of the long bones. In 
his opinion the advantage of this type of splint is that it makes possi- 
ble the achievement of anatomical reduction of fractures combining the 
principles of internal and external fixation without the necessity of open 
operation, A detailed description of the appliance is given. The author 
concludes that the advantages of this type of treatment are: (1) motion of 
joints proximal or distal to the fracturet(2) better attention to the skin 
in simple fractures ,(3) fixation of compound fractures while the wound is 
being cared for and (U) early and easier mobility of patients with result- 
ing reduction in nursing care* Complicationst- There was non-union in 2 
cases, and in three cases an infection developed severe enough to require 
removal of the splint* In general, there appeared to be some delay in 
union of fractures treated by this method as compared with the expected 
healing time of fractures treated by the usual conservative method* 
Waugh (62) discusses external skeletal fixation used with ordinary 
extension splints in the treatment of fractures of both bones of the leg* 
The author feels that even though some writers criticize the use of external 
skeletal fixation there is a definite place where this method can be used; 
for example, badly conminuted, compound, or oblique fractures of both bones 
of the leg are fractures which can be treated most satisfactorily by pin 
fixation. This is particularly true when the surgeon understands the basic 
principles of fracture treatment as well as those pertaining to the applica- 
tion of pin fixation* In 1926 the author described a simplified method of 
skeletal traction and counter-traction using a special pin holding clamp 
combined with ordinary extension splints* After further experience the 
author states that he is more enthusiastic than he was at that time in 
endorsing this simplified method of external skeletal fixation. He des- 
cribed this technique and equipment in detail including a discourse on 
equipment, application of the transfixion pin, technique of reduction and 
skeletal fixation in plaster* Key (63) discusses the complications of treatment of fractures by 
external skeletal fixation, and points out that the ingenious fracture 
reduction machines and external skeletal fixation splints require consider- 
able skill for the successful use on patients. Their use is not without 
danger and the following complications have been noted; (1) Infection 
around the pins which may involve the bone and even become extensive or 
generalized,(2) non-union which is believed to occur more frequently in 
fractures treated by this method than in those treated by more conserva- 
tive methods or even open operation and internal fixation,(3) failure of 
satisfactory reduction with resultant deformity, (i*) damage to important 
anatomic structures by the pin,(5) injury to joints and (6) Sudeck's post- 
traumatic atrophy. 
Devices for Internal Fixation: 
Harmbn7~~Baker and Renb~~(6U) report the results of experiments on 
the holding power of various types of metallic internal fixation for 
transcervical fractures of the femur. The data summarized in this report 
were secured in experimentally produced fractures across the femoral neck 
of 21*2 selected specimens. The estimations were of two types; the holding 
power against a distracting force directed coaxially with the neck and a 
determination of the resistance of the specimen to a superior, inferior 
crushing force. The experimental method used and the materials employed 
are described in detail in the article. Results of the tests are des- 
cribed in a well arranged table. Twelve types of internal fixation mater- 
ials that are commonly used in the treatment of transcervical fractures of 
the femur in man were employed in the tests. Included in the devices are 
multi-bladed nails, steel flanges, Steinmann pins, special slender pins 
and screws and various types of lag screws. Conclusion; Fractures immob- 
ilized by the hexagon headed, slender, stainless steel screws yielded the 
highest value on resistance to both distraction and crushing; the holding 
power of these screws against a distracting force was increased 1*5-75$ by 
reinforcing the trochanteric and upper lateral femoral cortex with stain- 
less steel washers and plastic plates; These values even exceeded the 
force required to pull the femoral head from an unfractured specimen. All 
the devices tested showed up well on crushing; especially high values were 
observed in the test for the Sraith-Petersen tri-bladed nail, several Stein- 
mann pins, the various lag screws, and multiple long hexagon headed screws. 
The results are given in 53 cases of transcervical fracture in man treated 
by early reduction in which the long hexagon headed screws were used for 
fixation. Direct union without other procedures was observed in 81*.9$, 
Trochanteric osteotomy within 6 months after fracture was performed in 6 
cases. The two instances of non-union were observed to follow reduction 
failure in one instance and to fracture of the screws in an unreasonable 
and hyperactive patient in the other. There were no instances of necrosis 
of the femoral head. The minimum follow-up period was one year and several 
patients were followed for six years. The long, slender, hexagon-headed 
screws serve as their own guide or pilot pin. They are introduced atrau- 
matically with a drill and can be withdrawn and re-inserted easily and 
without damage to the bone. The depth of insertion can also be adjusted 
after control roentgenogram. 
Lee (65) reports 1*2 cases of fracture of long bones treated by open 
reduction and screw fixation. Mentioning the disadvantages of traction 
methods he includes the requirement of constant supervision in order to insure the maintenance of the fragments in the correct position, the 
necessity for prolonged hospitalization, the danger of distraction of 
of the fractured surfaces, and the likelihood of angulation of the frag- 
ments. In outlining the advantages of screw fixation he includes the 
following: only a minimal period of hospitalization is required, the 
elimination of the danger of distraction, the possibility of early weight 
bearing, and the general improvement in the patient*s morale when early 
weight bearing is possible. In his opinion indications for internal 
screw fixation ares those cases in which one of the fractured ends do 
not permit locking of the fragments or in which strong muscle forces tend 
to maintain the fragments in displacement; when manipulative or traction 
methods have been tried and have failed; in the compound fracture in 
which a debridement leaves the fracture area widely exposed; in special 
cases such as in fractures of the shaft of the humerus when complicated 
or retentive dressings or apparatus must be worn causing discomfort for 
an obese patient; and in patients who prefer operative treatment in order 
to shorten the period of hospitalization. The author outlines the opera- 
tive procedure in detail and includes a careful analysis of the U2 cases 
reported upon* 
Adams and Coonse (66) discuss their experimental work in connection 
with tiie development of a method to obtain complete rigid fixation in 
fractures of the long bones by double plating. With the help of mechani- 
cal engineers a guide bar was developed for placement outside the wound 
with a tunnel guide running to the bone. The guide bar was gauged to the 
holes in the plate. Two yokes were then developed which were fastened to 
the bone itself and a reduction bar connecting them. The perfected machine 
attained the desired result in that the authors were able to place two plates 
on the bone over the fracture line and have the holes directly opposite each 
other. Stainless steel 18-8 was used throughout. The method was used on 
eight cases and all but two showed very definite aseptic necrosis the cause 
of which was found to be tortional strain plus lateral compression. The 
authors came to the conclusion that the mechanical results of double plat- 
ing definitely produced rigid fixation, but that Wolff>s law functions 
today as it has done in the past, and feel that this method should be 
thrown into the discard. 
(Ed. note (OSR); I agree that the procedure outlined by the authors should 
be discarded, but do not concur in the idea of abandoning the principle of 
double plating of fractures of the shafts of long bones. I have had the 
privilege of performing over 20 open reductions on the femur, in each in- 
stance using two stainless steel slotted plates for internal fixation. The 
plates were placed at right angles to each other, one on the anterior sur- 
face of the femur, the other on the lateral surface. The plates were cen- 
tered over the fracture site, but were offset from each other just enough 
to allow placement of the screws. Aseptic necrosis did not occur in any 
case. In the fresh cases, the patients were ambulatory in two weeks with- 
out ary additional support.) 
Follls (6?) discusses and illustrates the types of fixation he con- 
siders indicated in open reduction of fractures. Three procedures are 
outlined and illustrated with suitable cases along with their x-rays. 
First, two cases demonstrate the application of the wood screw principle to oblique and spiral fractures* Second, cases are shown to illustrate 
the use of bone plates in transverse fractures, and third, two cases are 
cited in which transverse fractures of the femur were treated with bone 
plates and no cast applied* The author believes that frequently when 
firm fixation is secured the cast can be eliminated especially in limbs 
that are not heavy. 
(Ed. note? Angulation of the fracture is liable to occur when only screws 
are usecffor fixation unless the cases are very carefully selected and 
unless the post-operative splints are very carefully applied and main- 
tained until the fracture heals.) 
Blade Plate Internal Fixation:- Umansky (68) reports a case of frac- 
ture of the* distal end of the femur in which he employed a blade plate for 
internal fixation of the fracture. There was an oblique fracture through 
the lower one-third of the shaft of the femur with marked lateral displace- 
ment of the distal fragment and about 2,f of overriding. Accordingly, 
skeletal traction with a Bohler-Braun splint was applied. Five weeks 
later there was an absence of callus and a continuous separation of frag- 
ments and great discomfort experienced by the patient. The fracture was 
then openly reduced and held in position with 3 screws. Ten days later a 
roentgenogram showed that separation of the fragments had taken place and 
also that one of the screws had caused further fragmentation. It was then 
decided to apply a blade plate for internal fixation of the fracture. At 
operation the previously inserted screws were removed as well as three 
rather large bony fragments. The angle of the blade was increased and the 
plate gently curved outward at the angle to conform to the lower lateral 
end of the femur. A blade 3A" shorter than the x-ray image of the pro- 
posed course was selected. The point of the blade was inserted about 1” 
proximal to the lateral condyle in order to avoid the knee joint and strip- 
ping of the suprapatellar pouch. With a small osteotome a cut was made 
in the femur at the site and the blade was driven in for 2/3 rds of its 
length securely anchoring the distal fragment. This was levered into the 
correct position by elevation of the plate parallel to the horizontal 
table top. The proximal fragment was then approximated to the distal 
fragment, and the blade driven home. Two Lawman bone clamps were used to 
hold the plate to the shaft of the femur while screws of appropriate 
length were inserted into the bone ends. 
Fractures of the Spine and Pelvis 
Crutchfield and Schultz (69) discuss the mechanism of the common 
spinal fractures. Regardless of mechanism of injury the resulting de- 
formities of the vertebral canal are constant. The vertebral canal is 
narrowed in its AP diameter by dislocation. Crushing injuries with wedg- 
ing and posterior displacement of the fragments into the canal are commonly 
seen in the thoracic region. Complete obliteration of the canal is seen 
in some of the more serious cases. The clinical picture of complete and 
incomplete transverse cord lesions is described. The treatment of these 
injuries is outlined in detail. Most impressive is the statement that no 
indication for cervical laminectomy has been found. The general care of 
the paraplegic is described in detail. Holdsworth (70) presents a series of fifty cases of disruption of the 
pelvic ring either by sacroiliac dislocation or fractures of the ilium 
or sacrum close to this joint. The former is twice as common as the lat- 
ter. These cases were treated with pelvic slings after reduction. Com- 
plications were unusual - only two with extraperitoneal rupture of the 
bladder, both of whom died; two with rupture of the urethra survived. 
Eight developed retroperitoneal hemorrhage probably due to laceration of 
the iliolumbar artery - four of them died. The prognosis in fracture - 
dislocation is good. Nearly all patients returned to heavy work. However, 
with sacroiliac disarticulation, the prognosis is not so good - only half 
returned to heavy work and there was often persistent sacroiliac pain. 
Arthrodesis of the sacroiliac joint was advised in these cases. 
Gallagher (71) presents four cases of fracture of the anterior iliac 
spine and indicates that the condition should be suspected when sudden 
severe pain develops in the inguinal region following either strenuous 
exercise or twisting of the hip in poorly conditioned adolescents. The 
pain is excruciating and there may be difficulty in walking and vomiting. 
Inability to raise the extended leg is constant. X-ray will prove the 
diagnosis. Treatment consists of bed rest for 2-3 weeks with knees and 
hips flexed and then gradual activity. 
Davis (72) presents a series of l£0 consecutive compound fractures 
treated by primary suture. 0ne hundred and thirty-one, or Q7% of the 
wounds healed by first intention. The author bases his excellent results 
on compression dressings, immediate coverage of the skin defect with 
skin or a split skin graft and thirdly to immediate or delayed internal 
reduction with metallic fixation when indicated. The use of penicillin, 
transfusions of whole blood and high protein diets also played an important 
role in the healing. Healing by first intention was found to be more fre- 
quent when radical excision of devitalized skin flaps was carried out. 
Relaxing skin incisions was the preferred method of skin closure with the 
resulting donor defects closed by split skin grafts. 
Special Fractures 
Astley and Shaw (73) present a case of fracture of the first rib 
bilaterally through the scalene tubercle due to the pull of the scalene 
muscles in a poorly trained individual under the sudden strain of stren- 
uous physical training. 
Burman and Sinberg (7h) describe fracture dislocation of the xiphoid. 
The xiphoicT is seldom injured. The force injuring the xiphoid can be 
applied in only one way, from anterior to posterior. Four forms of injury 
are possible; s(a) contusion or xiphoidalgia t(b) fracture at its junction 
with the sternum with stripping of sternal periosteum ,(c) fracture at its 
junction with the sternum with posterior dislocation and (d) fracture 
with displacement into the mediastinum. Treatment of the minor injuries 
consists of heat, massage, procaine injection and elastic strapping. 
Treatment of the more severe injuries not relieved by the above is by 
surgical excision. Foster and Wells (78) present 13 of Hi cases among high school 
athletes demonstrating fractures which were not recognized although the 
athlete continued through the season without diagnosis or treatment. 
The authors have proven that this is not an uncommon occurrence and 
demonstrate the need for medical surveillance of high school athletics. 
Some form of health insurance protection for these boys is desirable. 
These injuries most commonly involve the hands, feet, wrists, forearms, 
ankles and lower legs. Football is the outstanding producer of such 
injuries• 
Clough (79) describes various stumbling blocks in the treatment of 
fractures. Specific fractures are considered. Fractures of the navicu- 
lar prove difficult often not only in diagnosis but in obtaining union. 
The bipartite scaphoid will occasionally make diagnosis more difficult. 
The importance of accurate anatomical reduction of the radial fragment 
in a Colies1 fracture is discussed. The treatment of supracondylar and 
surgical neck fractures of the humerus are described. The author advo- 
cates internal fixation of all fractures of the femoral neck. He advises 
against promising too good a result in such cases because he thinks 70$ 
good results mmumsMi as can be expected, 
/are as good 
Ciccone and Richman (80) discuss a series of 2,709 fractures result- 
ing from parachute jumping in regard to mechanical etiology. Four re- 
current traumatic mechanisms became evident. The most common mechanism 
was torsion plus "landing thrust11. Backward landing caused by oscilla- 
tion of the parachutist was a common cause of vertebral fractures and 
craniocerebral injuries. Another mechanism of injury discussed was that 
due to opening shock of the parachute resulting in an arm or leg becoming 
entangled in the shrouds. The least common of mechanisms of injury was 
the violent vertical fall usually resulting in multiple injuries involv- 
ing the major weight bearing structures. 
Ainsworth and Wright (31) report their experimental studies of frac- 
tures sites • Simple, Compound and traumatized compound fractures were 
produced experimentally in dogs. The dogs were sacrificed in the 2nd, 
Sth, 7th, iSth and 21st days and serial sections through the fragment 
ends made. The cortical portion in the area adjacent to the fracture 
showed the lacunae to be entirely devoid of cellular content and the 
Haversian canals had undergone marked destruction. The most widespread 
devitalization was near the periphery of the cortex and the least in 
the marrow cavity. The least amount of devitalization was seen in the 
simple fractures and the most in the traumatized and compound group of 
fractures. The authors conclude that in the reduction of a fracture, 
devitalized tissue is approximated with devitalized tissue and the re- 
moval of this must be accomplished in the physiology of healing before 
solid bony union occurs. This tissue appears to have a local effect on 
the chemical composition and reaction of the hematoma and granulation 
tissue. 
Healing of Fractures 
Bick (82) discusses the structural patterns of callus in fractures 
of the Tong bones with reference to healing after internal fixation. Scuderi (7!?) discusses the more common sprains and minor fractures 
as to etiology, pathology, symptoms and signs, diagnosis, and treatment. 
The importance of x-rays to rule out associated fracture is stressed. 
The two classical forms of treatment - immobilization versus local inject- 
ion plus the use of the sprained joint, are discussed. Certain common 
minor fractures, particularly those of the phalanges, are discussed. He 
stresses the treatment of the fracture-sprains of the ankles and wrist 
by intnobilization in the over-corrected position. The importance of 
early diagnosis of subperiosteal fractures as well as their common sites 
is stressed. 
Cleveland (76) compares the total casualty rates during the recent 
war and those arising due to accidents in civilian life during the same 
time. Soldiers and sailors in combat and in training were exposed to 
hazards only ten times as frequently as civilians. Various emergency 
treatments were discussed. The emergency splinting of the lower extremity 
involves the use of the Thomas ring splint. For fractures of the foot and 
ankle wire ladder splints should be used. For fractures of the humerus a 
sling and swath should be used. For fractures of the forearm, wrist and 
hand, a well padded wire ladder or basswood splint should be used. Re- 
suscitation from shock involves the use of whole blood, not saline and 
plasma. The author discusses debridement and the importance of conserving 
all viable tissue. Similarly the secondary closure of compound fractures 
is emphasized. All bone fragments should be preserved if possible. Ampu- 
tations should be low as possible and circular in type. 
Curd (77) has presented pitfalls into which the unwary often fall 
in the treatment of fractures. These errors are divided into three 
classes depending on when they occur - before, during actual treatment, 
or during the healing period. The first and most serious error is the 
failure to assess the severity of associated traumatic shock. The failure 
to diagnose concealed non-bony injuries and all concomitant fractures is 
stressed. Failure to obtain adequate pre-operative x-rays and failure to 
interpret x-rays properly are pointed out as pre-treatment errors and in 
addition, failure to identify films is stressed as a not uncommon example 
of the wrong patient being treated. Proper recognition of the mechanism 
of production of the injury is recognized as of extreme importance for 
future treatment. Adequate medical records and the importance of notify- 
ing all concerned of the prognosis, are stressed. Among the serious 
errors resulting during treatment of fractures are delay in fixation, delay 
in reduction and inadequate reduction. Repeated attempts at reduction 
and the use of excessive padding under plaster lead to unfavorable conse- 
quences. He lists a broad group of technical errors during open operations 
and in treatment of compound fractures, particularly primary suture. The 
remaining errors occur during the healing period of the fracture. The 
failure to maintain close observation, failure to check maintenance of 
reduction, maintenance of an extremity in a non-physiologic position, the 
application of unpadded plaster in the presence of edema, the failure to 
instruct the patient in the use of prescribed appliances, too early mobili- 
zation, delay in rehabilitation, and lastly too early and ill-conceived 
physiotherapy are all mentioned as too frequent errors. After a series of tracings were made from unselected cases of fractures 
of the shafts of the long bones treated by standard nonoperative methods, 
3ick found regularly repeated patterns of the ossific mass about the 
fracture site. Only the structural outlines of the ossific mass was 
considered. The patterns appear to follow certain rules. These patterns 
of ossific mass about a fracture formed an external strut or brace tem- 
porarily holding two or more fragments in position and transmitting 
stresses outside the direct line' of the axis of the shaft. While being 
held up by these ossific struts, physiological resorption and replacement 
of the bone ends of the fragments can proceed as part of the process of 
reparative osteogenesis without collapse of the fracture space. The 
"volume of the external ossific mass appears to be in direct proportion 
to the degree of displacement". The hematoma appears to have no influ- 
ence on the development of the ossific mass. Where a plain undisplaced 
fracture exists the ossific mass formed is minimal while with total dis- 
placement it is greatest. The author stresses that the smaller amount 
of callus (ossific mass) seen with accurate open reduction and accurate 
fixation with plates or screws, etc., is dependent on the lesser dis- 
placement and should not be regarded as an indication of lesser callus 
because of plating or other metal fixation. He also points out that 
x-rays may be misleading in deciding the degree of healing. In his 
opinion clinical judgment of healing is more significant than x-rays in 
cases where internal fixation is efficient. 
The author outlines his opinions on the criteria of healing in frac- 
tures following internal fixation. He points out the lack of any actual 
criteria of healing or even definitions of healing. He defines two pert- 
inent phases in the tissue reaction of reparative osteogenesis; one of 
which he calls the phase of' ’’effective healing” and the other the ’’phase 
of replacement” • The phase of ’’effective healing” is defined as that 
phase of reparative osteogenesis in which the resistance of healing bones 
to stress and strain is sufficient to permit renewal of its normal func- 
tions within reasonable limits. In fractures of the long bones of the 
upper extremity this means manual work short of severe pressure or tor- 
sion; in the lower extremity it means ordinary unassisted weight bearing. 
The phase of ’’replacement” is defined as the phase of reparative osteogenesis 
during which the dense, fibrous fibrocartilaginous tissue of the internal 
callus is replaced by normally constructed bone trabeculae. This is said 
to occur concurrently with, but much slower than, the development of the 
uniting external callus which is the chief factor in the previously 
defined phase. Bick also is of the opinion that effective bone healing 
occurs in many cases long before x-ray films show completion of replace- 
ment by definitive callus. He found that in uncomplicated cases of 
rigid internal fixation, at least limited function could be resumed long 
before x-rays showed any of the accepted criteria of bone healing. He 
notes that James Paget and Dupuytren recognized the different functions 
of the ’’external or supportive callus” and the ’’internal or definitive 
callus” over a hundred years ago. In continuing the discussion the author 
states that in efficiently plated fractures the bone plate takes over the 
function of the external callus and permits resumption of the function 
of the bone as soon as its strength, plus that of the consolidated fibro- 
cartilaginous material of the internal callus established effective healing. 
3efore the "replacement phase” is completed the internal callus is radio- 
lucent thus leading to misinterpretation of degree of healing on x-ray 
188 films* This Minteraurface area" does not collapse during bone union 
and is filled with firm components of the so-called soft callus and is 
ossified eventually by replacement with bone cells and trabeculae* 
The appearance of considerable "external callus" in cases of internal 
fixation is indicative of either inadequate fixation or poor alignment* 
He found that in cases of efficiently plated fractures of the tibia 
and fibula guarded weight bearing could be started in six: weeks* Un- 
complicated plated fractures of the humerus required no plaster immobil- 
ization and guarded motion could be tested between the fifth and sixth 
weeks. Forearm fractures with either or both the radius and ulna plated 
required six weeks for safety. No time period for weight bearing on 
plated fractures of the femur was offered. BIBLIOGRAPHY 
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U. Masland, H. C.: Fracture deformity reduction and fixation splints; 
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5. Andreasen, A. T.j Avulsion fracture of lesser tuberosity of humerus; 
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19U8 30. Wahl, S.: Internal fixation of inter-trochanteric fractures in the 
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fixation, Pennsylvania M. J., 51: 759-766, Apr. 19U8 
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of 300 cases, N. Orleans M. & S. J., 100: Ii59-ii6ii, April, 19U8 
38. Neer, C. S. and McLaughlin, H. L.: Intracapsular fractures of the 
neck of the femur? Follow-up report of 130 patients treated by internal 
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the neck of the femur. Am. J. Surg., 76: 525-527, Nov. 19U8 
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tibia, Am, J, of Surg., 75: 796-801, June, 19U8 
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May, 19U8 
53• Callahan, J, J,t Recent and old fractures of the internal malleolus, 
J, Internet. Coll, Surgeons, 11j 35U-358, July-Aug. 19U8 
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tarsal fractures, J, of Indiana State M. A., 1*1: 1169-1170, Nov, 19U8 
55, Palmer, I.: Mechanism and treatment of fractures of the calcaneus, 
open reduction with the use of cancellous grafts, J. Bone and Joint 
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of the femur, U, S. Nav, M. Bull,, U8? 161-17U, Mar.-Apr. 19U8 
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Kiel, Lancet, 2: 387-388, Sept, li, 19U8 
61* Spriggs, J. B.: Haynes splint treatment of fractures of the long bone. 
Mil. Surgeon, 102j 191-193, March 19U8 
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splints in the treatment of fractures of both bones of the leg. Mil* 
Surgeon, 102* 188-191, March, 19U8 
63# Key, J. A.i Complications in the treatment of fractures by external 
skeletal fixation, J. Missouri M. A., hSi U22-U25, June 19^8 
6U. Harmon, P. H., Baker, D. R. and Reno, J. H.j Experiments on the hold- 
ing powers of various types of metallic internal fixation for trans- 
cervical fractures of the femur. Am. J. Surg., 76: 515-52U, Nov. 19U8 
65• Lee, H. G.s Treatment of fractures of long bones by open reduction and 
screw fixations report of U2 cases. Am. J. Surg., 75: 6U5-660, May 19U8 
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double plating fractures of long bones, Proc. Inst. Med. Chicago, 17: 
98, April 19U8 
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M. J., 1*6: 195-197, May 19U8 
68. Umansky, A, L.: Blade-plate internll fixation for fracture of distal 
end of femur. Bull. Hosp. Joint Dis, 9: 18-21, April 19U8 
\ 
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the spine. Am. J. Surg., 75: 219-226,Uan. 19U8 
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Joint Surg., 30A; 77-97, Jan. 19U8 
73. Astley, R. and Shaw, A. B.: A case of bilateral stress fracture of the 
first rib, Brit. M. J,, 2; 602-603, Sept. 25, 19U8 
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135; 820-823, Nov. 19U7 
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78. Foster, W. K. and Wells, J. C.: Unrecognized fractures in high school 
athletes, Minnesota Med., 31j 1206-1210, Nov. 19^8 
79* Clough, F. E.: Stumbling blocks in treatment of fractures, Journal- 
Lancet, 68: 100-103, March 19U8 
80. Ciccone, R. and Richraan, R. M.s Mechanism of injury and distribution 
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81. Ainsworth, W, H. and N. E.j Experimental study of fracture 
sites, J. Bone and Joint Surg., 30Aj U8—51, Jan, 19U8 
82. Bick, E. M.j Structural patterns of callus in fractures of long bones 
with reference to healing after internal fixation, J. Bone and Joint 
Surg., 30A: lUl-150, Jan, 19U8 SECTION 9 
FRACTURE DEFORMITIES 
Prepared by John T. Brennan, Lt, Col., M.C., U.S.A, 
Ayyar (1) reviewed the deformities arising following trauma in a 
general manner. In a discussion of the etiology and prevention of deformi- 
ties that ari.se from ununited fractures, malunited fractures, epiphyseal 
injuries, and unreduced dislocations, he lists stiffened joints, excessive 
shortening and malunion as causes of crippling. Lack of efficient after- 
care and of continuity of treatment is one of the causative factors. He 
states that, 
’’Every fracture should be looked upon as a potential deformity 
which may be traced to omissions and commissions or both; these 
may arise during treatment or after treatment.” 
He lists expert supervision, simplicity of apparatus, teamwork, segregation 
of fractures, and continued after-care as necessary to prevent deformities 
following trauma. 
A malunited fracture cannot be cured by operation alone. The operation 
can only reconstruct the fracture. A satisfactory result can only occur by 
the maintenance of alignment until consolidation is complete. This period 
required for consolidation differs with each fracture. During the period 
of maintenance of alignment, the muscles and other tissues should be exer- 
cised and kept efficient to prevent soft tissue deformity. 
The author reports that Volkmann’s ischemic contracture is commoner 
in India than any other part of the world. Besides proper prophylactic 
measures to prevent the occurrence of ischemic paralysis, he also recommends 
early surgery. In the care of injuries of the elbow, such as supracondylar 
fractures, if the edema is not subsiding or if there is severe pain, he re- 
duces the flexion angle of the elbow, elevates the extremity, and loosens 
all bandages, If these measures do not improve the condition he employs sur- 
gery. An incision three inches in length is made on the antero-ulnar border 
of the forearm, dividing the deep fascia and decompressing the forearm 
structures. He recommends exposure of the brachial artery at the bend of 
the elbow and above with resection of the artery is spasm is present. This 
must be done in six hours time. In the presence of the deformity he recom- 
mends early adequate splinting and encouragement of active movement. 
In discussing traumatic myositis ossificans as a complication appearing 
commonly after injuries in the region of the elbow joint, the author advocates 
the prophylaxis as follows: reduce the dislocation promptly with minimum 
force; treat supracondylar fractures as an emergency and reduce them cor- 
rectly; immobilize the elbow after reduction of elbow dislocations for at 
least three weeks, and restore movements of the elbow joint slowly in a case 
of supracondylar fractures. In restoring motion he gradually lowers the elbow angle one-half to one inch every day. He watches for spasm of the 
biceps muscle. When this, or the traumatic ossification is noted, the 
elbow is rested, allowing active movements only. The new bone formation 
may shrink and the condition may gradually improve. He does not recommend 
operative removal of the bony masses and bridges before six months* 
Phendster (2) discusses the causes of nonunion in fractures. These are 
local, and he lists the most important as* (1) inadequate fixation which per- 
mits of continuous trauma to the callus, (2) displacement of fragments which 
interfere with the establishment of a fibrous bridge and the impaction of 
coapted fragment ends by muscle pull, (3) infection of the fracture site, and 
(U) necrosis of the joint fragment in case of fractures bordering extensively 
on certain joints, such as the hip. If one or a combination of these factors 
remains sufficiently active beyond the normal healing time, the callus fails 
to ossify or even to fill out the space between the fragment ends, and non- 
union is established. 
The author does not believe, as many do, that these fractures must be 
broken down, the intermediary and intramedullary callus removed, and a bone 
graft applied with metal screw fixation. He advocates a more simple and 
efficient operative treatment. This consists of the simple application of 
a strong bone graft to the leveled side of the fragments, suture of the over- 
lying soft parts, and plaster immobilization for two to three months. Callus 
is thrown out from both the graft and the freshened surface of tthe shaft, and 
bony union is rapidly established between the two. The remaining old callus 
holds the fragments together and as motion is eliminated the intermediary 
callus, being less and less traumatized, becomes healthy and ossifies. He 
reports union of the fracture is usually present by the time the cast is re- 
moved, He recommends this treatment in case of fractures where the fragments 
are in good position. 
He reports more than one-hundred such fractures have been treated in 
this simple way with reduction at time of operation. Failure of union occur- 
red in but four cases. He believes that only a relatively small number of 
ununited fractures of the shaft are so widely displaced that it is necessary 
to break down the fracture line, remove the intermediary callus, and align 
and rigidly fix the fragments to the bone graft with screws or wires. (Ed. 
note* Many cases of nonunion of fractures are seen in which this simple 
operative approach to the problem can be used. The prolonged immobilization 
this method necessitates with the tendency to ankylosis of joints must be 
considered. In contrast, rigid fixation of fragments allows earlier mobiliza- 
tion of joints which prevents ankylosis.) 
Annersten (3) reports his observations of five cases of pseudarthrosis 
ensuing in fractures of the clavicle. He reviewed three hundred and fifty 
cases, Pseudarthrosis occurred in one and three-tenths per cent of these 
cases. In the same period of time the percentage of pseudarthrosis ensuing 
from a fracture of the forearm was between two and three per cent. He warns 
against being indifferent in the treatment of fractures of the clavicle since 
pseudarthrosis occurs more commonly than generally supposed. All of his cases 
clearly illustrate the characteristics of a fracture of the clavicle, i,e., 
dislocation of the lateral fragment caused by the weight of the arm. It is 
this dislocation which he believes plays the dominant role in producing the 
symptoms associated with pseudarthrosis. Only in one case did the patient complain of pain at the site of fracture. The remaining patients all gave 
a history of pain radiating down the arm, often accompanied by weakness of 
the arm or the hand; one patient complained also of sensory loss over the 
finders. These symptoms were less pronounced during the treatment when the 
arm was fixed because the lateral fragment was thereby kept in an elevated 
position. After immobilization was discontinued and the fracture failed to 
heal there was again depression of the lateral fragment and troublesome symp- 
toms become manifest. These symptoms accompanying the nonunion are similar 
in type to those which are produced by compression of the brachial plexus and 
observed in the scalenus-anticus syndrome. The costoclavicular space is nar- 
rowest between the first thoracic rib and a point lateral to the middle-third 
of the clavicle. It is just this point Which is most liable to injury and 
here the ulnar portion of the brachial plexus crosses above the first rib. 
The lateral fragment can readily squeeze the brachial plexus here, particular- 
ly if abundant callus is present which is often fomed despite the fact that 
the fragments have not united, A clavicular fragment which is displaced 
downward, may also cause compression on the brachial plexus. 
Satisfactory results were obtained in these cases after operative reduc- 
tion with reposition and wiring with drilling of the bone. The best results 
were obtained by the insertion of bone chips between the fragments and im- 
mobilization by an aeroplane splint for four weeks. In one case the symptoms 
of which the patient complained were made worse when during operation the 
fragment was lowered further. Since the weight of the arm causes downward 
displacement easily in these fractures, and the symptoms produced by nonunion 
seemingly are dependent upon this depression of the lateral fragment, the 
author believes that in treatment of fractures of the clavicle it is important 
that the arm should be raised and adequately supported until healing is com- 
plete , 
Wagner (h) presented a comprehensive paper on the treatment of metacarpal 
fractures, as well as the causes of malunion. He stresses the fact that the 
hand and fingers should not be overly immobilized. He also discussed the 
cause of disability brought about by immobilizing the fingers in extension. 
This produces capsular thickening and extension contracture of the metacarpo- 
phalangeal joints. The functional position of the fingers is stressed in 
treating metacarpal fractures. 
In treating malunion of metacarpal fractures, an operative procedure as 
employed by Bunnell is presented. This has given full function in the author’s 
hands. 
Rizzo and Lehman (5) presented a procedure for treatment of large bone 
loss of the tibia without the use of metallic or other foreign substance to 
maintain the position of donor grafts. This procedure was used by the authors 
because they observed that foreign material introduced into a healed compound 
wound caused an increased incidence of flare up of infection. The procedure 
used was as follows: 
A donor graft is removed from the longer of the tibial fragments, 
as long as possible, A second graft from the opposite leg measuring 
six to seven inches by five-eighths to three-quarters inch is inlaid 
in the site of removal of graft on the large fragment and inserted 
into the medullary canal of the shorter fragment• The other donor graft is placed on a prepared area of the lateral or medial aspect 
of the tibia. Bone chips are placed in the space between the grafts. 
Plaster immobilization is used until healing is complete. 
The author reports employing this technic in six cases with one hundred 
per cent success. 
Scuderi (6) reported his successful experience in performing ninety- 
four massive bone grafts in treatment of long bone defects, with the loss 
of three grafts due to infection and a fourth one due to refracture, requir- 
ing a second graft. He concluded that, in treating this type of defect, no 
definitive bone work can be performed until all the bone and soft tissue 
infection has cleared up and has remained clean for a minimum of three to 
four months. To obtain this, it was necessary to carefully debride the wounds, 
remove all dead bone and foreign bodies. Most of these cases were success- 
fully treated by the careful cleansing of the infected area, without sacri- 
ficing healthy bone or healthy soft tissue. Many of these cases so treated 
could be closed by interrupted black silk sutures, and then treated as a 
closed wound, instead of the old, well-known Orr treatment. The use of anti- 
biotics permitted a great deal of surgery which formerly was impossible. 
Eighty-five per cent of chronic osteomyelitis cases in battle casualties so 
treated healed by primary intention/ Fifteen per cent broke down and re- 
quired further surgery. In some cases, in order to close the defect it was 
necessary, in deep, wide wounds, after a thorough cleansing of the area and 
packing for three to five days, to place, a dermatome skin graft into the 
defect. In most of these cases primary healing of the skin graft was ob- 
tained. At a later date skin grafts of a full thickness type were used to 
fill the. defect, either as a swinging graft or as a pedicle graft from the 
opposite leg. The author used three types of bone for restoring the bony 
contour in defects of bone. Cancellous bone from the wing of the ilium was 
excellent for filling in defects. When besides bridging of defect, mechani- 
cal stability was necessary, tibia! bone grafts were most efficacious. Crest 
of the tibia was used when mechanical stability in addition to fresh bone was 
desired, as in the humerus and the femur, Tibial grafts from the central 
part of the tibia were used more commonly in the radius, ulna or fibula. 
Fibular grafts were found to be excellent where a large area had to be bridged 
such as a defect of five or six inches. The author’s personal experience 
showed they served beautifully in the reconstruction of the radius and ulna 
or in the filling in of a large defect of the humerus or femur, Fibular 
grafts were used in conjunction with tibial grafts to fill in defects in the 
femur. Firm apposition against the host bone was obtained by preparing an 
accurately fitting bed to permit maximal bone contact. Stainless steel screws 
were far superior to any other form of internal fixation. These bone grafts 
required a long period of external protection. Plaster of Paris was found to 
be the best external support for a bone graft. Grafts of the femur required 
five to six months immobilization followed by three to six months thereafter 
in a walking caliper. Tibial and humeral fractures required three to four 
months immobilization and later support by various types of braces. 
Farrow (7) records the experiences of bone grafting with autogenous bone 
in the treatment of 156 cases of fracture of the long bones with non-union 
or limited union, sustained as a result of war injuries. In 19 cases of 
limited union the bone was restored to approximately normal calibre. In 119 
cases of non-union with known end results, successful union was secured in 10U (87.1$)• Optimum time interval after drainage had ceased was discussed, 
quoting 72 cases with known time intervals. In fifteen patients operated 
upon after one to three month intervals, UO per cent developed infection; 
in 39 patients operated upon after three to six months, infection developed 
in 20,5 per cent. No infection occurred in 18 patients operated upon after 
intervals of six to eight months. The author suggests it is unwise to sub- 
stitute penicillin protection for an adequate waiting period. 
Rankin (8) presented a of his experience in performing one hun- 
dred consecutive bone graft operations in a naval hospital during World War 
II, These cases necessitated grafts for nonunion of fractures or those that 
presented defects to be bridged. The majority were performed in cases of 
war wounds that had previously had draining wounds. He concluded that the 
time element in the original treatment, the type of fracture, and the surgeon 
all contributed to the occurrence of nonunion in fractures. He applied grafts 
to the following bones: mandible 6, clavicle h, humerus 7, radius 16, ulna 
13, radius and ulna combined 9, scaphoid 10, thoracic cage defect 3, femur 
10,, tibia 18, internal malleolus U, Four cases showed a small pocket of pus 
at the time of operation. The bone grafts were completed and the wounds were 
closed. Sulfadiazine was given as well as penicillin in these cases. One 
of the wounds healed per primum. Two wounds drained but eventually healed 
with preservation of the grafts and union of the fracture. In the fourth 
the operation failed. 
Of ten ununited scaphoid fractures, six healed with bony union following 
grafting. Four returned to regular duty and two to limited duty because of 
some pain and about twenty five per cent limitation of motion. Four had no 
union but apparently enough fibrous union to return to limited status. The 
following fracture cases were sent to limited duty because of nerve injury* 
four radius, three radius and ulna, and two humerus. All the remainder re- 
turned to full duty. He concluded that of the patients treated by bone graft- 
ing for nonunion a high percentage should be able to return to normal activi- 
ties. 
In the humerus, femur, and tibia sliding inlay grafts were used princi- 
pally, The recipient areas were prepared with osteoperiosteal flaps turned 
down over the graft when it was placed on the shaft. In bony defects dual 
grafts were used. Bone chips from the ilium were used in addition to bridge 
defects. Chip rib grafts were used for bone defects of the clavicle. Ribs 
and iliac grafts were both used in fractures of the mandible through external 
incisions. Often in these mandibular fractures preliminary intraoral opera- 
tions were-necessary to restore normal alignment because of shortening and 
deformity of the mandible. Stair-stepping the ends in some cases in humeri 
and forearm bones was used where it was not necessary to maintain normal 
length. This was of advantage where severed and retracted nerves were pres- 
ent, In the forearm this procedure or resection of the distal ulna, was used 
when it was impossible to maintain length of the radius, Thoracic cage 
defects were improved by transplanting ribs and good functioning and cosmetic 
results were obtained. 
The author believes bone grafting is successful if certain rules are 
observed, Preoperatively the draining wounds connected with the fracture 
must be treated by the simplest procedure possible and extensive dissections 
and curettments are to be condemned. Proper skin coverage must be obtained 
200 prior to any grafting procedure, A waiting period of approximately two 
months is recommended from the time drainage ceases until the bone grafting 
can safely be performed. This is due to the advent of the antibiotics. 
The waiting period can be utilized by physiotherapy to improve movement of 
joints and the circulation of the part. Penicillin is used pre- and post- 
operatively. At operation the author recommends the use of intravenous 
glucose and whole blood to compensate for loss of blood and body fluids. 
The draping should be done by the surgeon and not a third assistant; fine 
cotton should be used for ligation of vessels, avoiding mass ligation of 
tissue; and sponges are to be used once and discarded. The periosteum is 
disturbed as little as possible. All scar tissue is removed from the end of 
the bones and the medullary canal is opened widely with drill holes. Screws 
retaining the grafts are placed as far from the fracture site as possible 
and must traverse both cortices. Prior to closure a debridement of all de- 
vitalized tissue is performed, all dead space is eliminated, and the skin is 
closed with interrupted cotton sutures. (Id. note* The opinion as to the 
optimum time interval between cessation of infection and surgery varies with 
the experience of different surgeons. Many advocate longer waiting periods 
than two months,) 
Moore (9) discusses the statistics concerning fractures of the neck of 
the femur. One of the best statistical reviews is the report of the fracture 
committee of the American Academy of Orthopaedic Surgeons in 19L1. Two 
hundred and forty one cases were reviewed. The Smith-Petersen nail was used 
in lUU cases, the percentage of union was 72,9; multiple pins were used in 
83 cases, the percentage of union was 62,7; miscellaneous internal fixation 
methods were used in kh cases, percentage of union was 85. Cf the cases 
reduced successfully, approximately 2k per cent showed arthritic changes with 
pain, stiffness and disability in the two year follow-up. Faulty reduction 
possibly accounted for 75 per cent of the failures. Loss of blood supply 
to the head possibly accounted for 25 per cent. There appears to be a very 
definite group, approximately 15 to 20 per cent, which fail regardless of 
reduction and type of internal fixation. It is this hopeless group in which 
there is loss of blood supply to the head for which some type of reconstruc- 
tion operation is essential. 
Moore presented a reconstruction operation for nonunited fractures of 
the neck of the femur. This was based primarily on the utilization of the 
cartilage of the head of the femur at operation. He utilizes the dead head 
or the live head of the nonunion. He removes the bony contour of the head 
completely with the exception of the layer of bone attached to the cartilage. 
After a section of the trochanter is removed with the muscle attachments, 
he then carefully replaces the reamed-out cartilaginous cup of the proximal 
end of the femur. He reattaches the trochanter to the shaft of the femur 
with the aid of wire suture or vitallium screws. The method consists essen- 
tially of transplantation of hyaline cartilage. The author states the pro- 
cedure is not successful unless the cartilaginous cup is accurately fitted 
to the neck and maintained in this relationship until it is united. The 
average time for union is between eight to twenty weeks and the patient is 
immobilized in a plaster of Paris hip spica. The author presents no sta- 
tistical follow up on patients treated by this method. 
Ivins and Ghormley (10) presented their evaluation of the Brackett oper- 
ations performed from 1920 to 19U5. Seventy one cases had this procedure. with fifty per cent of these performed in the last three years. Thirty two 
per cent had undergone one or more operations elsewhere previously. Eignt 
cases were discarded because follow up observations were not adequate, leav- 
ing sixty-three cases for analysis. The operative technic employed, especia- 
lly in the later group of cases, was the Brackett operation as modified by 
Magnuson in 1932. Internal fixation of some sort was used in fifty five cases, 
or seventy seven and five-tenths per cent. Vitallium screws were used in 
forty-four cases and this was their internal fixation of choice. 
The results showed one hospital death, or a mortality rate of one and 
six-tenths per cent. The results were: Good - 66.6 per cent; fair - lh*3 
per cent; and poor - 17*5 per cent. (Favorable - 60.9 per cent). Of the 
eleven cases of failure, four had slipping of the head from the shaft, three 
cases showed typical aseptic necrosis, and in one nonunion developed with 
absorption of part of the head of the femur. One did not stop using crutches 
due to other causes occurring eighteen months after operation. One case of 
nonunion showed union between the head of the femur and the acetabulum at 
later operation and another was a failure because pain persisted after the 
operation. The authors recommend the procedure. They regard the proper 
selection of cases, careful operative work, valgus position of the femoral 
head on the remodeled shaft and adequate internal fixation as the factors 
which determine the success of this procedure. 
Dickson (11) presented an excellent paper on the subject of treatment 
of ununited fractures of the neck of the femur. He confined his discussion 
to those cases in which it would seem possible and feasible to restore ana- 
tomic and physiologic function to the hip joint. He believes that when it 
is recognized that nonunion is developing the fact should be accepted immedi- 
ately and an appropriate operation for correction carried out. When nonunion 
once starts it almost invariably goes from bad to worse, and delaying surgery 
allows atrophic changes to develop in the head of the femur. This makes the 
end results of secondary treatment more problematic. The earlier the opera- 
tion is performed for nonunion the better the results that can be expected. 
The author discussed the advantages and shortcomings of various accepted 
methods of handling the problem of nonunion. An analysis of his results with 
varied procedures as well as a review of the literature showed that the 
proportion of failures, amounting to thirty-five to fifty per cent of all 
cases subjected to secondary procedures, was remarkably similar in all meth- 
ods . 
The author proposed a procedure to combine the advantages of the vari- 
ous procedures — osteotomy, internal fixation, and bone graft. The aim is 
to correct the faulty mechanics by lowering the shearing angle to restore 
circulation and to stimulate formation of bone all in a single operation. 
Technics The trochanter is exposed through a lateral curved incision 
between the tensor fascia lata and the gluteus medius. The outer surface 
of the bone is prepared for a blade plate. The joint capsule is opened and 
a guide wire is placed from a point about one-half inch above the prominence 
of the greater trochanter into the center of the head. Then a blade plate 
is bent to form an angle with the shaft of sixty degrees when inserted paral- 
lel to the guide wire. The blade plate is then properly placed. The osteot- 
omy site is determined by a proper size semi-hexagonal chisel. One side of the chisel parallels the flare of the trochanter, extending downward from 
the blade plate before the osteotony site is marked. The inner blade mark 
comes out just above the lesser trochanter, thus assuring a high osteotony. 
The osteotomy is then completed and rotation is accomplished, as well as 
fixation, A window is then made in front of the trochanter segment just dis- 
tal to the fracture line. Through this window the sclerotic bone and fibrous 
tissue are removed from the fracture line, Curettement up into the head al- 
lows numerous chips of cancellous bone from the ilium to be impacted well 
across the fracture line, and one large graft is fixed into position to give 
added stability. The window can be replaced. Internal rotation is maintained 
postoperatively for six to eight weeks; then the patient is allowed up on 
crutches with no weight bearing for a period of months. X-ray progress stud- 
ies show when this protection may be discontinued when there is evidence of 
thorough revascularization of the head. 
TTith this procedure the author reports solid union in nine of ten cases. 
The one case in which union had not occurred resulted in a good, stable, 
functioning hip. There was roentgenographic evidence that healthy bone had 
formed in the head of the femur in which there was increased density, indi- 
cating reestablishment of circulation to the head. This fact, and other 
observations, has led to considerable difference of opinion as to what con- 
stitutes a "dead" head and as to the procedure that may be effective in the 
presence of roentgenographic evidence of aseptic necrosis. The author cau- 
tions that it would seem wise to assume a cautious and conservative attitude 
toward removal of "dead" heads, since there is a possibility for regeneration 
of bone in a large proportion of these cases, The combined operation he 
advocates has resulted in regeneration and revascularization of bone in ro- 
entgenologic ally "dead" heads in cases of two and three years duration. 
The author suggests that reevaluation of these fractures by a mechanical 
analysis in relation to impaction and position of the fracture in relation 
to the interruption of blood supply may furnish an approach toward classifi- 
cation and prognosis of cases at the time the fracture occurs. In cases in 
which preliminary study indicates that impaction is unlikely to occur with 
simple nailing, some type of operation designed to bring about impaction and 
stability of the fracture might be performed as a primary procedure. The 
author would favor the controlled osteotomy to correct this if this were used, 
in properly selected cases. BIBLIOGRAPHY 
1. Ayyar, N. S, N,j Consideration of deformities after trauma. Antiseptic, 
U5: 73-85, Feb. 19U8 
2. Phemister, D. B-s Biological principles in the treatment of ununited 
fractures, Proc. Inst. M, Chicago, 17: 1U1, June 15, 19U8 
3. Annersten, S.j Ununited clavicular fractures, Uppsala Lak., Foren., 
Forb., 53: 29-37, 19U8 
U. TTagner, C. J.; Corrective osteotomy and capsulectomy in treatment of 
malunion of metacarpal fractures, Mil, Surgeon, 103: 3UU-3U8, Nov, 19U8 
5. Rizzo, P. D. and Lehman, 0,: Repair of massive defects of tibia with- 
out fixation. Am. J. Surg., 75: 516-518, Mar, 19U8 
6, Scuderi, C.s Treatment of long bone defects by bone grafts, J. Indiana 
M. A., Ul: U00-U02, Apr. 19U8 
7« Farrow, R. C.: Summaiy of results of bone grafting for war injuries, 
J, Bone and Joint Surg,, 30A. 31-39, Jan. 19U8 
8, Rankin, J, O.s Management of the ununited fracture. South. Surgeon, 
13: 785-809, Nov. 19U7 
9* Moore, J, R.j Reconstruction operation for nonunited fractures of the 
neck of femur. Recorder, Columbia Medical Society Richland Co,, Columbia, 
S. C.,-12; 10, May, 19U8 
10, Ivins, J, C, and Ghormley, R. K,; Brackett operation for ununited 
fractures of the neck of the femur. Surgery, 22: 819-825, Nov, 19U7 
11, Dickson, J, A.: Treatment of ununited fractures of the neck of the 
femur, J. a. M. A,, 137; 1199-1206, July 19U8 SECTION 10 
TUMORS OF BONE AND SOFT TISSUE 
Prepared by August W, Spittler, Colonel, MC, U.S.A, 
and Resident Staff 
Tumors in General: Diagnosis, Treatment, Classification, etc* 
Phemlster (1) reports 23 cases of sarcoma with 7 long term survivals, 
treated by resection and bone transplantation. Only one of these cases was 
an osteogenic sarcoma, however. Coley, et al (2) advocate a less radical 
procedure than amputation and suggest the role of less radical amputation 
if indicated, substituting a high thigh for a hip disarticulation, etc. 
They suggest segmental resection and partial resections of the bone which 
is involved. 
De Los Santos (3) gave a discussion of the most common malignant tumors 
of bones, their recognition and treatment as seen in the National Orthopedic 
Hospital, stressing early diagnosis and radical treatment. He also discussed 
the metastatic tumors and hormonal therapy, 
Lawrence (U) in discussing isotopes in neoplastic disease, says the 
greatest contribution of their use will be in tracer studies of metabolism 
and its therapeutic value is still not understood too well. 
Hatcher (5,6) recommends regional resection of tumor and conservation 
of function when possible. He states that progress is about as good with 
amputation. He does advocate an amputation of leg in highly malignant tumors, 
Brailsford (7,8) decries the widespread belief in the infallibility of 
histological examination of biopsy material and believes the radiological 
features are sufficient for the majority of diagnoses, 
Wheelock (?) reviews the pathology and classifies the bone tumors on a 
histologic basis. He believes the pathologic basis for treatment should be 
used with the objective of curability with least impairment of function. 
Holmes, et al (10) gave a study of the incidence in 16,363 roentgeno- 
grams of bone with a finding of 106 bone tumors or 0,63$, Of these there 
were 35 exostoses and solitary cysts, U multiple myeloma, 3 osteogenic sar- 
coma, 1 Ewings tumor and 1 endothelioma, 52 metastatic tumprs from breast 
and prostate cancer, and 10 soft tissue tumor with involvement of bone by 
direct extension, 
Guri (11) gives a review of literature of Tumors of the Vertebral Column, 
both of the primaiy type and those of metastases from other tumors, 
*ibex 01 
Joynt and Ortved (12) report a case of accidental operative transplanta- 
tion of a benign giant cell tumor to the ilium which was made as a donor site 
for the filling of the defect made by curettage of the original lesion in a 
tibia, Malignant Osteogenic Tumors 
Osteogenic Sarcoma,-Ackerman (13) reports two cases of multiple 
osteogenic sarcoma. The evidence was not in favor, however, of multiple 
primary origin but emphasizes that multiple bone lesions are not always 
due to non-osteogenic origin. 
Moore (ll;) reports a case of periosteal osteogenic sarcoma in a 15 
year old boy following trauma. Trauma occurred 3 years previously. (Ed, 
note: Although it was thought for years that trauma was only coincidental 
in these cases, there is increasing evidence that it does play a part,) 
A case of an enormous tumor of the shoulder treated palliatively with 
shoulder girdle amputation was presented by Cornell and Jones (15). 
Warren (16) discusses a case of Paget's disease of the skull with sar- 
comatous degeneration in a 60 year old woman. The average age is 66 years 
with the disease present for 12 years, 
Howard (17) believes osteogenic sarcoma should be treated by x-ray 
rather than radical surgery, 
Griswold (18) reports a case of osteochondrosarcoma of the sternum 
treated by resection and replacement with a tantalum plate which was unsuc- 
cessful because of trauma and bleeding on respiratory movements, 
Ewing's Sarcoma.-Endothelioma of Bone (Ewing's sarcoma) by Coley, et al 
(19) gives an excellent discussion of this tumor based on the author's con- 
clusions on 73 cases. Pain is almost always the first symptom, in an age 
group of from 5 to 25 years which affects males in a ratio of 2 to 1, They 
bring out the similarity of the process to an infectious or inflammatory 
process, its early metastasis, and uniformly poor end results. They list a 
survival rate of k.1% for five years with palliation as the only treatment 
available, this being best achieved by roentgen therapy, 
Mabrey (20) gave a case report of a case diagnosed clinically as a 
chondrosarcoma in a 19 year old male which was treated by resection of the 
lower one-half of the sacrum and entire coccyx and proved to be an endo- 
thelioma on pathological study. 
Metastatic Bone Tumors 
Shockman and Harrison (21) in a discussion on Occult Bone Metastases 
believe that the methods of clinical and radiological surveys do not dem- 
onstrate many lesions, and that the skeleton often shows many on careful 
study by hand lens at post-mortem followed by microscopy. The marrow is 
often filled and the bony architecture not altered. 
Coles and Schulz (22) reviewed 288 cases of malignant lymphoma over a 
10 year period with T3$ showing bone involvement. Bone involvement did not 
affect the prognosis. Silverman (23) presented a study of clinical and roentgenographic obser- 
vation in 103 infants and children with skeletal lesions in Leukemia, He 
stressed the value of a bone biopsy, 
Colson and Willcox (2h) report 3 cases of bronchiogenic cancer metasta- 
sizing to phalanges of hand, toe and a metatarsal, 
Smedal and Salzman (25) present the data on 100 consecutive cases of 
treatment of metastatic bone tumors. They believe x-ray therapy should be 
given only when symptoms are present, and is the best palliative treatment 
available. Hormonal therapy was effective in the bone metastasis from car- 
cinoma of prostate. Limited use of radioactive substance, radioactive iodine 
and phosphorus was reported. 
Benign Osteogenic Tumors 
Osteoid Osteoma.- Lapidus and Wilson (26) presented 3 cases of osteoid 
osteoma with a brief discussion of the clinical characteristics. They 
believe Roentgen control or surgery is indicated. 
Osteoma.- Brunner and Spiesman (2?) report U cases of osteoma involving 
frontal and ethmoid sinuseiT They should be surgically removed if any 
tendency to expand exists. The mixed type is most frequent, spongious core 
and compact cortex. 
Ossifying Fibroma of Bone.- Shaefer (28) reports a case of adamantinoma 
of the mandible treated afterrecurrence with resection and replacement with 
rib, • 
Exostoses.- (Ollier’s Disease).- Dickson and Cohen (29) reported a case 
of hereditary deforming chondrodysplasia in a 22 month old child giving the 
family background. 
Fun-Yong Khoo, et al (30) reported 7 cases in Chinese subjects. They 
believe that it is a disease also of the flat bones. Treatment only as symp- 
toms arise or permit for the surgical removal of those offenders. 
Giant Cell Tumors,- Roy (31) reports a case of benign giant cell tumor 
of the sacrum in a 20 year old male, treated by x-ray with later curettage. 
The areas recalcified with no return of symptoms, 
Chikianco (32) reports a benign giant cell tumor in the tibia and fibula 
of a 10 year old boy with 6 year follow-up following x-ray therapy. 
Bone Cysts and Fibrous Dysplasia 
Fibrous Dysplasia, Polyostotic and Monostotic.- Sante (33) correlated 
the x-ray pathology and clinical findings in polyostotic fibrous dysplasia 
and compared it to Ollier’s Disease as well as other diseases presenting 
cystic changes in bone. Clinically fibrous dysplasia of bone is insidious 
in onset, and has extra-skeletal lesions such as abnormal patches of skin pigmentation and sexual precosity. The x-ray findings show tiny cyst-like 
areas in cortex, she11-like thinning of cortex, spontaneous fractures, no 
periosteal elevation, no general osteoporosis but a sclerosis of involved 
bone, widening and elongation of the shaft and a tendency to unicameral in- 
volvement. Brooke (31+) confirms the discussion of Sante, In his differen- 
tial diagnosis the condition to be most often confused with ostei- 
tis fibrosa cystica, 
Wooley and Alpern (35) report a case of a 3 year old negro child with 
typical findings, Bingold (36) reports a case and discusses the 
pathological and x-ray diagnosis, Hammond and Sponsel (37) report a case 
treated with bone graft from mother. They revealed that 39 cases were re- 
ported in the literature up to 19U5. 
Schlesinger (38) reports a case of monostotic fibrous dysplasia of the 
tibia in a 3 year old male who had an amputation 5 years later after numerous 
operative procedures for pseudarthrosis, 
Ayers (39) reports a case involving a rib and claims that this is the 
most common location for a single bone involvement. Excision is the treat- 
ment of choice, Mammel (1*0) compares localized fibrous dysplasia and ossify- 
ing fibroma and believes they can be considered to be variants of the same 
process, 
A case of solitary bone cyst of the os calcis was reported by Hundley 
(1+1), He states that only 1; cases were reported in the literature. (Ed. 
note; This lesion is much more common than this would indicate.) 
Heublein and Baird (1+2) report a cyst of the ilium as an uncommon site, 
Leslie and Stenhouse (1+3) report a case of localized osteitis fibrosa 
of the skull. 
Synovioma 
Harris (1+1+) presents 3 cases of synovioma, in the ankle region, calf 
muscles, and adductor region of the thigh, 2 cases survived amputation, but 
the case involving the adductor thigh muscles succumbed 7 months postopera- 
tively, 
Kessel (1+5) reports a 38 year old female with a synovioma of the region 
of the lateral malleolus. Below knee amputation was done but check x-rays 
have shown metastases, 
Warren (1x6) presents a case of a 31 year old female with a fixed subcu- 
taneous mass in the sole of the foot, diagnosed synovial sarcoma although 
not involving any joint* Radical resection is indicated including removal 
of regional lymph nodes, 
Johnson (1+7) differentiates between synovioma and synovial fibrosarcoma. 
Synoviomas contain endothelium-lined cavities, metastasize to regional lymph 
glands, are radio-sensitive; synovial fibrosarcoma do not and in addition 
often contain irregular calcific deposits* Multiple Iforeloma 
Scott (U8) reviewed the clinical and pathological aspects of multiple 
myeloma with presentation of 5 cases. The average age was 55. Secondary 
anemia was a constant finding with pain the most frequent symptom. 
Langley (h9) reports 7 cases in an age range from 53 to 69. One case 
was treated with stilbamidine with relief of pain and disappearance of the 
Bence-Jones proteinuria. 
Baker and Casterline (50) report U cases treated with stilbamidine. 
They felt that no effect was received. 
Snapper (51) says that Q0% of cases are partially relieved of pain by 
stilbamidine and that the drug appears to have an affinity for the abnormal 
nucleoproteins of the myeloma cells. 
Cope and Wyman (52) report a case with normal serum protein in a 72 
year old woman! 
At the CPC of Medical College of Alabama a case of multiple myeloma was 
presented and the findings outlined by Stokes, et al, (53). 
Spitzer and Price (5U) report a solitary nyeloma of the mandible in a 
3U year old male and Chesterman (55) wrote on the follow-up of solitary plas- 
mocytoma of the long bones, presenting U cases treated by surgery with U to 
12 year survival, one with amputation and others with curettage and bone 
grafting. 
Lumb (56) reports a case of solitary plasmocytoma of sacrum only found 
at autopsy after it was suggested by the clinical course of the disease. 
They 
Eosinophilic Granuloma 
Ponseti (57) presents 8 cases of bone lesions, in eosinophilic granu- 
loma Disease and Letterer-Siwe Disease, to show that 
they represent forms of the same pathological process* He believes that the 
solitary eosinophilic granuloma is the mildest form of this group of diseases* 
In the case where there is involvement of other organs besides bones it is 
convenient to group them under a common heading with Hand-Schiiller-Christian 
Disease and Letterer-Siwe Disease* The cause may be a low grade infection. 
X-ray therapy has a favorable influence on the lesions. The older the patient 
the more favorable the prognosis. 
Baker and Fisher (58) report h cases of eosinophilic granuloma of the 
skull with a 5 year follow-up* They report some cases of spontaneous resol- 
ution in their review of the literature. 
W. J. Baker, et al (59) support the relationship of the disease to 
Hand-Schiiller-Chris tian1 s Disease. They emphasize that all symptoms are due 
to local lesion. A typical case in a 39 year old male was reported. Conran, (60), Schroff, (61), and Kauffman (62) reported cases involving 
the jaws, 
Kendrick and Woodruff (63) report a case of eosinophilic granuloma 
involving the scapula, a portion of a rib and areas of a dorsal vertebra in 
a 12 week old white female. There was an associated cutaneous lesion simu- 
lating an impetigenous eruption over the trunk. Diagnosis was confirmed 
by biopsy of scapula. All lesions responded to radiation therapy with com- 
plete resolution of the osseous lesion. 
Weaver (6U) reports a case in a 32 month infant. 
Schuknecht and Perlman (65) bring out that a lesion may manifest itself 
first by erosion or perforation into an external auditory canal or into 
sinuses, or even a facial nerve paralysis first. The lateral supraorbital 
region of frontal bone appears to be the site of predilection for solitary 
granulomata. If surgery is done without a positive diagnosis, it should be 
followed by irradiation. 
Dill (66) reports a 5 year old child with onset as a mastoid involvement 
and later a parietal bohe involvement, 
Ackerman (67) reported a case with involvement of lung and diaphragm. 
Love and Fashena (68) reported a case which first manifested itself as 
an eosinophilic granuloma and later as a Hand-SchUller-Christian Disease, 
Maurer and DeStefano (69) reported a case with rib involvement, Dickson (70) 
reports a case with diffuse pneumonia involvement of lung. 
Sarcoidosis 
Cameron (71) discusses the clinical aspects of Sarcoidosis and feels 
that it may be a tuberculosis of a fibrosing and non-cassating type. Cystic 
changes in bone occurs in 20% of cases usually in the heads of phalanges, 
metacarpals or metatarsals, diagnosis can only be made by histological exam, 
of involved tissues,,,,tt showing the epithelial tubercle, 
Pautrier (72) discusses the most prominent etiologic factors and believes 
that tuberculosis or an unknown virus causes it, Freudenthal (73) gives the 
pros and cons for the tuberculous origin. Snapper (7U) feels that it may be 
a separate entity, 
Fischl and Freireich (75) report a case with fatality due to hemoptysis. 
Hurst (?6) reports a case and suggests that superficial lymphadenopathy with 
unexplained pulmonary x-ray changes should always suggest it. The hand showed 
typical lesions. 
Reeves, et al (77) review the literature briefly and report 13 cases in 
children, most ot which had no bone involvement, 
Ustvedt (78) gave autopsy findings in 3 cases. They all had hilar adeno- 
pathy with fibretic strands containing numerous nodules of epithelial cells, fibroblasts and Langhan's cells without caseation or necrosis. One case 
died of hemoptysis from cavitation in lung. He suggests that the tuber- 
culous theory is due to chance only in that it was found in only 18$ of 
cases autopsied. 
Cartilaginous Tumors 
Shellito and Dockerty (79) studied U2 cases of cartilaginous tumors of 
the hand. The enchondromata were 3 times more prevalent than ecchondromata. 
Their recommended treatment was conservative surgery. 
Miscellaneous 
Metabolic DiseasesShort (80) discusses osteomalacia associated with 
steatorrhea. There was no diarrhea, nor inadequate diet in one case of a 
50 year old white female reported. A study showed a high fat residue in her 
stools with a serum calcium and phosphorous belcw normal, A pancreatic 
deficiency is thought to be the cause. 
Miscellaneous,- Hauser and Constant (81) report a case of skeletal hem- 
angioendothelioma, The authors believe that, though rare, it must be consid- 
ered in all skeletal lesions which are cystic, trabeculated, invading soft 
parts. They recommend surgical treatment. 
Hatcher (82) discusses extraskeletal ossification simulating sarcoma. 
He does not believe that the term myositis ossificans and calcifying hema- 
toma are appropriate to describe heterot/opjrtic ossifications about joints or 
in muscles. The young reactive fibroblastic tissue replacing damaged muscle 
is considered responsible for the formation of bone and cartilage. Immature 
bone trabeculae later form in the ossifying mass. The mass later may surround 
or attach to bone and is not a projection of the bone itself. 
Jaffe and Lichtenstein (83) report and describe 8 cases of a distinctive 
benign tumor of bone which they name chondronyxoid fibroma. These tumors 
have probably been reported previously as enchondroma and myxoma or their 
cancerous counterparts. They interpret the lesion as a peculiarly differen- 
tiated connective tissue tumor, exhibiting in the course of its evolution, 
certain chondroid and also myxoid traits which hallmark, the lesion cyto- 
logically. It is composed of cells lying loosely in a myxoid intercellular 
matrix, which as the tumor matures, may undergo substantial collagenization. 
The tissue in any particular speciman may also come to simulate cartilage 
tumor tissue in some fields, and its gross appearance, likewise, bears a 
certain resemblance to cartilage. The presence of smaller or larger numbers 
of tumor cells exhibiting nuclear atypism may cause the lesion to appear 
more ominous than it is known to be, explaining why it may come to be over- 
diagnosed as a malignant tumor, particularly as chondrosarcoma. 
The lesion was usually found in the femur, and tibia, in the metaphyseal 
area adjacent to the knee joint. In these bones the lesion did not extend 
across the entire width of the raetaphysis, but did erode and even substan- 
tially destroy the local cortex, causing bone contour to become bulged. Where a demarcating cortical shell was absent, it was evident that the tumor was 
still contained by the periosteum and the overlying parosteal connective 
tissue. On its inner surface the tumor is usually bordered by a zone of 
sclerosed bone. 
Most of the patients were adolescents or young adults. The lesion 
evolves slowly, it is apparently benign and does not tend to recur after 
curettage. Its recognition is of importance in that pathologically it may 
readily be mistaken for sarcoma and, as such, treated more radically than 
is necessary. 
Schorr, et al (8U) report a case of chondroma of lumbar vertebra mis- 
taken for a tuberculous spondylitis until excised and examined histological- 
ly. 
Ross (85) reports 2 cases, a sacro-coccygeal chondroma and a metastatic 
carcinoma to sacrum. In his review of sacral and presacral tumors he found 
1 case in U6,183 admissions. 
Hawk and Hopkins (86) discuss 25 cases of malignant tumors of the soft 
tissues of the extremities. Fibrosarcoma was present in 19 with 1 each of 
neurogenic sarcoma, synovial sarcoma, angiosarcoma, rhabdomyosarcoma and 2 
myosarcomata. Mortality rate was 65$* with 30% being without disease due 
,to amputation or excision and S% living with disease. Excision either by 
amputation or local if possible was favored. 
Reissman (8?) gives a brief discussion of Schuller-Christian's Disease 
and raises the question of whetherHthere is a differentiation between lipoid 
granulomatosis of the bone Schuller-Christian's Disease. 
Potter and Coverstone (88) report a case of a chondrodystrophic infant 
bom to dwarfed parents with the same condition. Only two cases have been 
reported before with both parents and child having this condition. BIBLIOGRAPHY 
1, Phemister, D, B.: Treatment of selected cases of bone sarcoma by 
resection and bone transplantation, Ohio State M. J., UU: 1119-1122, 
Nov, 19U8 
2. Coley, B. L, and Higginbotham, N. L,: Conservative surgery in tumors 
of bone with special reference to segmental resection, Ann, Surg., 
127: 231-2U2, Feb. 19U8 
3* De Los Santos: Some common malignant tumors of bone, their recognition 
and treatment, J. Philippine M. A,, 2ki hhl-hS9, Aug, 19U8 
!*• Lawrence, J, H*: Isotopes in neoplastic disease. Rocky Mountain M, J,, 
U5: 980-98U, Nov. 19U8 
5. Hatcher, C. H.s Diagnosis of bone sarcoma. Rocky Mountain M, J,, hSi 
968-979, Nov. 19U8 
6, Hatcher, C. H.j Treatment of bone sarcoma, Rocky Mountain M, J., U5i 
999-1009, Nov. 19U8 
7* Brailsford, J, F.; Serious limitations and erroneous indications of 
biopsy in the diagnosis of tumors of bone, Proc. Roy. Soc. Med., Ul: 
225-236, Apr. 19U8 
8, Brailsford, J, F.s Serious limitations and erroneous indications of 
biopsy in the diagnosis of tumors of bone (Editorial), Radiology, 51: 
< 733, Nov. 19U8 
9. M. C.: Pathology of bone tumors, J. Iowa M, Soc,, 28: 522- 
527, Dec. 19U8 
10, Holmes, L, P,, Robingson, D. and Brown, S. W.j Incidence of bone tumors 
in a large general hospital, J. M. A. Georgia, 37: 7U-80, Mar. 19U8 
11, Guri, J", P.: Tumors of the vertebral column, Surg, Gynec. and Obst,, 
87: 583-598, Nov. 19U8 
12, Joynt, G. H, C, and Ortved, W. E.: Accidental operative transplanta- 
tion of benign giant cell tumor, Ann. Surg,, 127: 1232-1239, June, 19U8 
13* Ackerman, A. J.: Multiple osteogenic sarcoma, report of two cases. Am. 
J. Roentgenol., 60: 623-632, Nov. 19U8 
1U. Moore, M. R.: Periosteal osteogenic sarcoma of the right femur follow- 
ing trauma; case report, Connecticut M. J,, 12: 715-716, Aug. 19U8 15. Cornell, V. H. and Jones, H. W.j Case of osteogenic sarcoma. Bull. 
U. S. Army M. Dept., 8: 78, Jan. 19U8 
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Missouri M. A., U5: 3h8, May 5, 19U8 
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688, Dec. 19U7 
19. Coley, B. L., Higginbotham, N. L., and Bowden, L.j Endothelioma of 
bone (Ewing’s sarcoma), Ann. Surg., 128: 533-560, Sept. 19U8 
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Surg., 35: 385-389, Apr. 19U8 
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Radiology, 50: U58-U62, Apr. 19U8 
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819-8UU, June 19U8 
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carcinoma. Lancet, 1: 100-102, Jan, 17, 19U8 
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Wisconsin M. J., U7i 675-686, July 19U8 
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'and Laryng., 
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33. Sante, L. R.t Polyostotic fibrous dysplasia (Albright's syndrome) and 
its comparison with dyschondroplasia (Ollier's disease). Radiology, 5l: 
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36; 22-26, July 19U8 
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report, Guthrie Clin. Bull., 18: 77-82. Oct. 19U8 
38. Schlesinger, P. T.s Case of fibrous dysplasia with pseudarthrosis. 
Bull. New York M. Coll., 10; 20-22, 19U7 
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right ilium, Am. J, Roentgenol., 59: 699-70U, May 19U8 
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the skull, Brit. J. Surg., 36; 211, Oct. 19U8 
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Mar. 6, 19U8 
U5. Kessel, A. W, L.; Synovioma of right ankle region, Proc. Roy. Soc. 
Med., Ul; 383-386, June 19U8 
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29: 356, 19U8 
U8, Scott, W, F,; Multiple myeloma, Jefferson Hillman Hosp. Bull,, 2; 
3U-4|2, Jan. 19U8 
U9. Langley, W, D,* Multiple Doyeloma, Quthrie Clin. Bull, 17: 179-183, 
Apr, 19U8 
50, Baker, R. T, and Casterline, R, F,: Multiple myeloma, A report of 
experience with stilbamidine. Am, J. M, Sc,, 216; 183-187, Aug, 19U8 
51* Snapper, I.; Treatment of multiple myeloma with stilbamidine, J, A, 
M. A., 137; 513, June 5, 19U8 
52. Cope, 0, and Wyman, S, M.t Multiple myeloma - case record of Mass, Gen, 
Hosp,, New England J, Med,, 239 1 376-3 78, Sept, 2, 19U8 
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of case, J. M, A, Alabama, 17; 317-323, Mar, 19U8 
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M. J., 1: 1027-1028, May 29, 19^8 
55• Chesterman, J, J,j Solitary plasmocytoma of the long bones, Brit, J, 
Surg., 35j UUO, Apr. 19U8 
56, Lumb, G,; Solitary plasmocytoma of bone with renal changes, Brit, J, 
Surg,, 36; 16-22, July 1, 19U8 
n 
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Christian disease, and Letterer-Siwe disease, J, Bone and Joint Surg., 
30A; 811-833, Oct, 19^8 
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report of four cases with five-year follow-up, S, Clin. North America, 
28; 1057-1070, Aug. 19U8 
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granuloma; report of case with x-ray evidence of rapid progression. New 
England J, Med,, 238; 626, Apr. 29, 19U8 
60. Conran, W. R,; Eosinophilic granuloma of the mandible - report of case, 
J, Oral Surg,, 6; 260-262, July, 19U8 
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26U, Mar, 19U8 
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J. Oral Surg,, 6; 260-262, July 19U8 63. Kendrick, J, I, and Woodruff, J, B,, Jr,: Eosinophilic granuloma, re- 
port of case with both osseous and cutaneous lesions, Cleveland Clin, 
Quart,, 15s 26-29, Jan, 19U8 
6U« Weaver, R, M.: Clinicopathologic case record, Delaware State M, J,, 
20: 1U8, July 19U8 
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and eosinophilic granuloma of skull, Ann, Otol, Rhino, and Laryngol, 
57: 6U3t676, Sept. 19U8 
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diabetes insipidus, Ann, Otol, Rhino, and Laryngol,, 57: 531-537, 
June 19U8 
67* Ackerman, A. J,: Eosinophilic granuloma of bones, associated with 
involvement of the lungs and diaphragm, Amer. J, Roentgenol,, 58j 
733-7UO, Dec. 19U7 
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Hand-Schuller-Christian disease, J, Pediat., 32; U6-5U, Jan. 19U8 
69* Maurer, E, and DeStefano, G. A.: Eosinophilic granuloma of rib, J, 
Thoracic. Surg,, 17: 350-356, June 19U8 
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involvement, California Med,, 69r 51-53, July 19U8 
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case report. New York State J, Med,, b8: 2U01-2U03, Oct, 15, 19U8 
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107-111, May 19U8 79# Shellito, J. G. and Dockerty, M. B,$ Cartilaginous tumors of the 
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Obst. and Gynec., 56$ 790-793, Oct. 19U8 SECTION 11 
CONDITIONS INVOLVING THE LOWER PART OF THE BACK 
Prepared by Lloyd W. Taylor, Lt. Col., M3, USA 
From the number of papers written on subjects related to the low 
back we must conclude that low back conditions are among the most import- 
ant current problems with which the orthopedic surgeon is called upon to 
diagnose and treat. The intervertebral disc syndrome was the most dis- 
cussed subject of all low back conditions. 
Jones (1) gives an interesting review of the highlights of the chang- 
ing trends in the treatment of backache by eminent authorities. A discuss- 
ion of the syndrome of the low spinal disc includes the concept of injury 
as an etiological factor even in normal backs without lumbar lordosis. 
Faulty posture which causes even normal activity to become trauma is con- 
sidered an etiological cause. 
Early symptoms located in the lower back but after recurring 
attacks the pain is referred to the hip or the mid-gluteal region followed 
by pain down the leg. The pain does not necessarily follow the distribu- 
tion of the sciatic nerve but picks out the areas supplied by the spinal 
nerve root. The overlapping of nerve roots makes it necessary to have 
two adjacent roots affected to produce anesthesia while involvement of 
one will effect paresthesia. Later in the development of the disc syn- 
drome the density may be constant and the remission incomplete. 
Treatment should include continuous rest in bed during the acute 
period without active physical therapy. Additional rest of the lower 
anatomical part of the low back is provided by corsets, braces and casts. 
Heat and massage are recommended when accompanied by relief of pain. 
Manipulation may offer some benefit in patients undergoing exacerbation 
and remissions but should not be utilized when irreducible protrusion of 
the disc is present. Novocaine injections are not utilized because of 
the lack of good evidence and information as to their benefit and curative 
value. Medication for relief of acute pain is imperative. In the choice 
of treatment patients are divided into three classes of mild, moderate 
and severe and treatment selected to fit the severity of the case. Con- 
servative care is indicated until incapacity is clearly demonstrated, 
but surgery should not be unnecessarily deferred. Classification of causes 
of back pain are listed below. 
I. POSTURAL STRAIN 
(Chronic drag of gravity) 
II. TRAUMA 
1. Injury to soft tissues 
2. Injury to vertebrae and joints 
3. Injury to intervertebral discs III* INFECTION 
1* Spondylitis deformans 
2. Fibrositis and myositis 
3• Actinomycos is 
1;* Blastomycosis 
5>* Brucella abortus 
6. Osteomyelitis 
A* Pyogenic organism 
B• Typhoid 
7* Epidural abscess 
8. Neisserian involvement 
IV. CATCH ALL CLASS 
(Growth disturbances, metabolic, endocrine, senes- 
cent and neurotropic) 
1. Osteochondritis (Calve) 
2* Adolescent epiphysitis (Scheuermann) 
3* Senile epiphysitis and osteoporosis 
h» Neuropathic joints of tabes and syringomyelia 
5* Parathyroid tumor 
6. Paget*s disease 
7• Gout 
V. CONGENITAL ANOMALIES 
1* Defects of isthmus (most important) 
A. Spondylolisthesis 
B* Spondylosis 
2. Spina bifida (occulta) 
3* Asymmetrical lumbosacral facets 
h. Sacralization transverse processes 
Lurabarization transverse processes 
6. Extra or deficient vertebrae 
7• Wedged vertebrae 
VI. NEOPLASTIC 
1* Benign 
A* Osteoma and osteochondroma 
B* Giant cell tumor (may be malignant) 
C• Hemangioma 
D* Eosinophilic granuloma 
2* Malignant 
A* Primary 
a* Sarcoma and osteogenic sarcoma 
b. lymphoblastoma 
c. Multiple nyeloma 
B. Secondary (metastatic) 
a. Carcinoma of breast 
b. Hypernephroma 
c. Thyroid 
d. Prostatic carcinoma 
3* Tumors of the spinal card, its meninges, roots 
and the filum terminals 
220 VII. VASCULAR 
1. Aneurysm 
VIII. PSYCHOGENIC 
1. Hysteria 
2. Malingering 
3• Psychoneuros is 
Butler (2) presents a review of the role of the general surgeon in 
the management of low back pain, including history taken, physical exam- 
ination performed, and general causes of low back pain along with differ- 
ential diagnosis and treatment. Included in the general surgical causes 
of low back pain, attention is invited to the incidence of this complaint 
in those patients suffering from carcinoma of the rectum, diverticulitis, 
bowel obstruction, gastrojejunal ulcer, advanced ulcerative colitis, 
Meckel*s diverticulum, intra and extra peritoneal enlarged nodes, abscesses, 
cysts and tumors, as well as metastatic malignancy and strangulated inguinal 
hernia. In differentiating patients with backache referred from the above 
conditions, it is well to remember that patients with surgical lesions of 
the esophagus, stomach, duodenum, biliary tract, pancreas and diaphragm 
have referred pain to the back, but at a higher level than other general 
surgical conditions of the low abdomen. 
The usual conservative measures of treatment of patients presenting 
themselves with complaints of backache are followed. Only those patients 
suffering from a mild degree of low back pain are treated as ambulatory 
patients; the rest are given bed rest. Those patients with marked pain 
and spasm of the low back, particularly those with sciatic scoliosis are 
routinely hospitalized. Unless satisfactory remission of pain and tender- 
ness is accomplished in approximately seven to ten days, the patient*s 
spine may be gently manipulated. Manipulation is performed with or with- 
out anesthesia, depending upon the degree of relaxation desired. Manipu- 
lation is not performed in cases with marked arthritis, spondylolisthesis 
or ruptured intervertebral discs. While hospitalized these patients are 
treated intensively but treatment is not terminated with discharge from 
the hospital and a home program of treatment is outlined, including physio- 
therapy, and strengthening exercises for the back abdominal musculature. 
Belts, braces and casts are recommended, but caution should be followed 
to prevent overuse. 
The major proportion of patients suffering from low back pain, with 
or without sciatica, will recover under a conservative plan of treatment. 
Where conservative treatment is not indicated, or has not been successful 
in a reasonable length of time, the patient should be referred to an 
orthopedist or neurosurgeon for more specialized diagnosis and treatment. 
It must be remembered that low back pain may be the presenting symptom in 
an entirely unsuspected malignant disease of the rectum, sigmoid colon 
and other pelvic structures. Any patient with unexplained low back pain 
who has not had this possibility fully explored has not been completely 
examined or worked up. 
King (3) discusses back pain from the gynecological standpoint. He 
states the exact mechanism by which pain is produced and the anatomical 
pathways along which the afferent stimuli travel in those patients having backache in association with gynecological problems is not completely 
understood* Greenhill states that "the backache in less than half of 
all women is due to disturbances in the pelvic organs or to abnormali- 
ties in the kidneys." It is likewise generally held that backache of 
pelvic origin is fairly definitely localized to the sacral area and 
that pain above this region is not due to pelvic pathology. 
Back pain due to abnormalities of position of pelvic organs is not 
fully understood. A uterus that is normal in size, shape and mobility 
but which has assumed a retroposition practically never gives rise to 
back pain. The recognition of this fact has led into decreased incidence 
in uterine suspension operations among competent gynecologists. If symp- 
tomatic relief is obtained with the uterus held in antiflexed position and 
if the retroposition and pain return when the pessary is removed, the 
possibility of operative measures can be considered, but under no other 
circumstances. A relaxed vaginal introitus occasionally gives rise to 
backache as a chief complaint, but this is uncommon. Usually the complaint 
of backache in these patients is not the chief complaint. When it is the 
predominant symptom one should be very cautious in promising relief follow- 
ing the correction of the relaxation. 
Back pain due to inflammatory reaction in the pelvic lymphatics, par- 
ticularly along the course of the uterosacral ligaments, as evidenced by a 
thickening and induration of these structures, accompanied by tenderness 
and pain, can often be relieved by satisfactory treatment of the inflam- 
matory condition. Occasionally amputation of the infected cervix will be 
necessary before a cure can be obtained. Patients suffering with inflam- 
matory involvement of the upper generative tract frequently respond to 
suitable therapy. This can be considered as a differential diagnostic 
point between pelvic inflammatory disease and acute appendicitis. Acute 
appendicitis almost never has backache among the complaints of the patient. 
Backache is a common symptom in patients suffering with chronic inflam- 
matory disease of the pelvic organs, particularly in those patients where 
adhesions are present between the posterior parietal peritoneum and the 
adnexa or uterus. 
Back pain due to tumors and cysts is surprisingly unconmon. The 
pull or stretching of the pedicle of an ovarian cyst will occasionally 
be associated with backache. Myomatous tumors of the uterus practically 
never cause back pain unless there is associated pelvic inflammatory con- 
dition with the presence of adhesions. 
Back pain due to endometriosis is found in those patients with involve- 
ment of the posterior surface of the uterus and the cul-de-sac, accompanied 
by dense adhesions running to the rectum and the posterior parietal peri- 
toneum* 
Back pain in association with premenstrual tension and/or dysmenorrhea 
is probably due to congestion as a result of an increased pelvic circu- 
lation and associated edema of the pelvic tissues. These patients are 
occasionally helped by the use of ammonium chloride, testosterone and 
progesterone. Back pain due to psychogenic states is a difficult decision to reach 
and should not be determined until all gynecological, orthopedic, urolog- 
ical and neurological causes have been ruled out. The response of these 
patients to treatment will depend upon the duration and degree of the 
fixation, the etiology of the mental state, and the ability of the invest- 
igator* Psychiatric help should be obtained in the management of these 
cases when it seems indicated* 
Platt (i|) gives a historical review of the stages through which our 
present knowledge of the pathogenesis of the backache-sciatica syndrome 
has been reached* Diagnosis of the cause of sciatica, can be approached 
by the recognition of five main groups: (1) Pelvic visceral disease* (2) 
Bony lesions of the lumbar spine, pelvis and femora, i*e*, destructive 
lesions, inflammatory or neoplastic* (3) Joint lesions of the spine, 
pelvis and hips. In this group the protruded disc had displaced sacroil- 
iac strain and vertebral arthritis as the dominant lesion, but these two 
were still real lesions and sciatic pain was common in osteoarthritis of 
the hip joint* (ii) Central nervous lesions proper, e.g., cauda equina 
tumors. (£) Pseudosciatica; fibrositis of the fascial, ligamentous and 
muscular structures in the lumbar region, buttocks and thighs. This type 
of "sciatica" was numerically important; fibromyositis might of course 
cloak an underlying arthritis of the lumbar spine in which degenerative 
changes were likely to be present in the intervertebral discs. 
In comment. Professor Geoffrey Jefferson agreed that a single brief 
attack of sciatica might conceivably be due to neuritis, but could not 
prove the point, and believed this etiological agent to be a rare disease. 
A survey collected by letter interview revealed two-thirds of a group of 
twenty-six unoperated patients to have continued attacks of pain while 
three had been badly handicapped. This survey was in line with the Scan- 
dinavian reviews of close to £00 patients and indicated little support to 
the contention that sciatica was commonly a transient and unimportant 
disorder. Relapses in unoperated cases could be accounted for in three 
ways: (1) Because there is from time to time a sudden further small pro- 
trusion of disc tissue. (2) Because the prolapsed disc remained unchanged, 
there are recurrent episodes of edema and congestion. (3) Because tension 
excited by the hernia is intermittent, the disc popping in and out. 
This latter process was difficult to believe since the hernia prob- 
ably caused pain by tension rather than pressure on the nerve root. Prof- 
essor Jefferson said that 82$ of 130 cases operated upon by himself or 
his assistants had obtained complete relief of pain, or had only a small 
amount of residual pain. Results of this order were considered good and 
surgery indicated. The relation between disc herniation and sciatica was 
now firmly established, but the history and clinical signs of cases with 
a disc lesion were often identical with those where there was no such 
lesion, and the differences must be discovered before improved results 
were to be obtained. 
Ytreheus (5) presents an exhaustive survey of 2£6 patients, including 
men and 106 women whose sciatica was managed conservatively. As 
Laseguefs sign is the cardinal symptom in sciatica, the patients were divided into three groups as follows: Group Is Positive Lasagne*s at 60° 
or more: £0 patients (20$); Group II: Positive Lasegue1 s at 30° to 60°: 
13k patients (££$); Group III: Positive Lasegue*s at 30° or less: 72 
patients (2£$). 
The principle adopted for treatment in this series of cases has been 
absolute confinement to bed until the patient is free from pain when at 
rest and until positive Lasegue is not attained before at about 60°. Anal- 
gesics and salicylates have been employed in association with massage and 
x-ray has been utilized in those patients who demonstrated radiographi- 
cally spondylitis deformans. Injection treatment and brace have been em- 
ployed only in a couple of the cases of this series. The follow-up in- 
vestigation of these patients was made by means of inquiry form (in which 
special stress was laid on particulars respecting subjective symptoms 
and disability) and li;0 patients of this group were personally examined 
by the author. In 10? cases the information submitted regarding subsequent 
incapacity for work was checked by inquiries addressed to the sick-insurance 
offices. The average time spent in hospital was 37*2 days and the average 
number of days illness was 97*3• Forty-seven percent were free from symp- 
toms when discharged from the hospital. Material is divided into three 
groups according to results of the Lasegue test and the three groups differ 
distinctly with reference to the length of time spent in the hospital and 
duration of the period of disability. Seven of the patients were operated 
for sciatica. Of the remaining 213 patients 33*8$ were found on re-examin- 
ation to be fully capable of work and free from pain, 37$ were fully fit 
for work but still had some subjective troubles, and 26.8$ had more or 
less reduced ability to work on account of sciatica.* None of the patients 
re-examined were quite incapacitated for work from the disease and only 
3.3$ had been obliged to seek lighter employment. In 2.U$ the capacity 
for work was reduced owing to other causes. Thirty percent of the patients 
have had recurrences which in 10.8$ of the cases necessitated readmission 
to the hospital. In general, the more positive the Lasegue1s sign, the 
longer the duration of illness, the poorer the results and the more prob- 
able the readmission to the hospital. 
In conclusion the author briefly discusses the indications for opera- 
tive treatment which are primarily grave neurological defects, intolerable 
pain and failure to respond to conservative treatment. If after three 
months the patient does not show satisfactory progress and has pain which 
is incapacitating, the case should be reviewed for consideration of surgery. 
No patient should be subjected to an operation before he has undergone 
careful medical treatment in the hospital. 
Boysen (6) surveys the material of U31 patients suffering from sciatica 
from the three medical departments of Oslo Municipal Hospital in the period 
between 1938 and 19Ui*« The material consists of 220 men and 211 women. 
The disease affects the right sciatic nerve just as frequently as the left 
one. Fourteen percent had bilateral pain. Most of the patients were be- 
tween 26 and £0 years of age, with a distinct maximum of the age group, 
36 to i|0 years. The average duration of hospital Stay is twenty-one days, 
the patient having reported sick an average of three weeks before admitted 
and five weeks after discharge. Lumbar puncture, neurological examina- 
tion and x-ray examination of the lumbar column, pelvis and both hip joints has been performed on a great number of these patients. The results 
of these examinations $ and especially their prognostic value, is discussed. 
Two hundred seventy-seven patients are control-examined. Of these 183 
are personally examined by the author. The time of observation is from 
two to eight and one-half years. Substantial weight is laid on estimat- 
ing the patient’s capacity of work, the obtained relief of symptoms and 
continuation of pains with possible relapse resulting in a renewed con- 
finement to bed or a further stay in hospital. Eighty-six and five- 
tenths percent of the patients are in full work, 11.5# have had to take 
lighter work and 0.7$ are completely unfit for work. Twenty-one and one- 
tenth percent are free from symptoms, while 78.8$ have continued pains 
in a greater or lesser degree and 30$ of the 277 patients have had a re- 
lapse. After the age of 1;6 years relapse is rare. One cannot draw any 
prognostic conclusions on the basis of the length of anamnesis, duration 
of stay in hospital, the result of the examination of the spinal fluid, 
x-ray examination or the neurological examination. The conservative treat- 
ment has beens absolute confinement to bed, analgesics, local warmth and 
massage. In the case of spondylosis x-ray treatment was applied. Sixteen 
patients were operated on of which ten were free of symptoms after the 
operation, two have continued pain and two have been operated on too 
recently to include in this survey of observations. In the cases where 
there are strong persevering pain and considerable neurological defects, 
operation is definitely indicated, otherwise the subjective inconvenience 
and reduction of the capacity of work must be a deciding factor. A final 
standpoint as to the time in the development of the disease when the 
patient ought to be subjected to an operation can only be taken when a 
sufficiently extensive material of operated patients, where substantial 
weight is laid on the control-examination with regard to the capacity of 
work and continuation of the pain after operation, is available. 
Between 1936 and 19h% most of the cases of sciatic pain treated at 
Princess Elizabeth Orthopaedic Hospital were treated primarily by the use 
of relative immobilization of a plaster jacket, and this paper by Durbin 
(7) is a sumary of the results. Included in this survey are only those 
patients with positive neurological signs such as absent ankle jerks, 
diminished ankle jerks, absent knee jerks, sensory disturbance, muscle 
wasting etc. Two hundred twenty-five patients with these signs were 
treated but it was not possible to trace 78 of these patients. Of the 
llj.7 who were traced, including 82 men and women, 123 were treated by 
relative immobilization in a plaster jacket from two inches below the 
nipple line to the symphysis pubis anteriorly and to the lower part of 
the sacrum posteriorly, and kept in this position for two to three months. 
The plaster jacket was applied with head traction in order to steady the 
spine. In the majority of eases ambulation was possible as soon as the 
plaster was dry, and pain was much relieved within one or two days. If 
pain persisted the patient was kept in bed and skin traction was applied 
to the leg. The application of a plaster corset is better than simple 
recumbency in bed because it affords more complete protection of the lum- 
bar spine, thus allowing more complete relief of nerve root irritation, 
and encouraging reduction of the prolapsed intervertebral disc. Simple 
bed rest over a period of many weeks offers less control of spinal move- 
ment, delays rehabilitation of the patient and involves wastage of hospital 
beds. Of the 123 patients treated i*3 were cured (3l*$), 35 were relieved 
(29%), and 1*5 were not relieved (37$)• 
It is clearly shown that relief or cure by simple plaster immob- 
ilization becomes less as the duration of symptoms increases; The more 
complete the neurological signs, the less is the prospect of relief by 
simple immobilization. Of 21 patients who before treatment displayed 
all three signs; diminished or absent ankle jerk, hypesthesia and wasting 
of the calf, only 1k% were cured, 1*8$ were relieved and 38$ were not 
relieved. It is evident that when an ankle jerk is once lost it is un- 
likely to return, but that diminution of an ankle jerk often disappears 
when symptoms are relieved. Furthermore, sensory disturbances due to nerve 
root pressure persist in the majority of cases. 
In a detailed discussion of fibrositis Traeger (8) calls attention 
to the confusion and controversy regarding this disease entity which he 
believes is due to the following factors: (1) Diagnosis and classification 
are difficult because of the paucity of objective findings, such as lab- 
oratory and x-ray evidence, absence of temperature, swelling and inflam- 
mation, (2) Because of the nature of the disease, biopsies are rarely 
obtained and the pathology of this disease entity, if indeed it can be 
so described, is obscure, (3) No definite etiology has been proved, (h) 
The disease is usually self-limited, Fibrositis, excluding the traumatic 
type, may be classified into three groups; (1) Primary fibrositis, a 
disease entity that exists independently and is not accompanied by any 
other definite disease; (2) secondary fibrositis, a disease entity which 
occurs coincidentally with other diseases, such as gonorrhea, infectious 
fevers, gout, rheumatoid arthritis or osteoarthritis, rheumatic fever and 
trauma; (3) senile fibrositis, in involvement of the fibrous tissues of 
the body as a natural accompaniment of the aging process. In this chapter 
primary fibrositis only is of clinical importance. In secondary fibro- 
sitis the diagnosis and treatment are obviously directed to the accompany- 
ing disease. 
History; Fibrositis was originally described by Jaccoud but the 
present designation dates from the introduction of the term by Gowers 
in 1901*, and by Stockman in 1933 and 1931*• 
Etiology; The etiology is unknown. 
Diagnosis: Diagnosis is made by a process of exclusion. There is 
no external evidence of joint pathology. Roentgen examination of the 
joints is negative. There are no significant constitutional reactions, 
such as fever, anemia or loss of weight. There are no abnormal lab- 
oratory findings. 
Symptomatology; In the acute variety, the diagnosis is made chief- 
ly on the presenceof local muscle tenderness, pain and spasm, and the 
absence of any other objective findings. In the chronic forms, diagnosis 
is made from the subjective findings of stiffness and aching of the muscles, 
joints and periarticular regions, and from the presence of the so-called 
11 jelling phenomenon1', which is a particular sort of stiffness that is 
alleviated by moderate exercise and aggravated by over exertion. There is usually an exacerbation of symptoms by cold and damp weather and a 
diminution of symptoms during warm or dry weather. 
The differential diagnosis between fibresitis and rheumatoid arth- 
ritis is reflected in the tabulation listed belows 
DIFFERENTIAL DIAGNOSIS 
Fibrositis 
Rheumatoid Arthritis 
Limited to a definite area 
Polyarticular involvement as a rule 
Tenderness a variable factor 
Tenderness frequently outstanding 
symptom 
Presence of stiffness or "jell- 
ing phenomenon", which disapp- 
ears quickly after exercise or 
movement* Very frequently the 
first symptom the patient with 
fibrositis complains of is this 
"jelling" or stiffness of the 
joints after long periods of 
rest, such as sitting in a 
theater seat, playing bridge 
or on arising in the morning. 
Stiffness persisting after motion 
or exercise 
Muscular atrophy rare 
Muscular atrophy quite common 
Synovial exudate never found 
Synovial exudate a frequent finding 
Pain elicited only on extremes 
of motion or any type of forced 
movement that produces tension 
of the capsule 
Pain on motion of affected joint a 
characteristic symptom 
Pain frequently relieved 
after moderate exercise 
Pain increased by motion or exer- 
cise or weight-bearing 
Frequent remissions 
Remissions uncommon 
Systemic manifestations 
uncommon 
Systemic manifestations comprising 
slight rise of temperature, loss of 
weight, loss of appetite, secondary 
anemia and low blood pressure 
Slight capsular thickening 
possibly present 
Capsular thickening possibly present 
Elevated sedimentation rate 
and secondary anemia rare 
High sedimentation rate and second- 
ary anemia frequent Differential Diagnosis (Cont*d) 
Fibres it is 
Rheumatoid Arthritis 
No roentgenologic evidence of 
bony involvement 
Roentgenologic evidence of bony path- 
ology a rule 
Pathologys The pathology of this disease has been inadequately 
studied because of the lack of biopsies. Authorities disagree on the 
pathological findings of the specimens that have been observed. A 
great deal more work needs to be done in this field before a differential 
diagnosis can be made on a pathological basis. 
Distribution: The most common are intramuscular fibrositis and 
periarticular fibrositis. These two types may exist either separately 
or together in the same patient or they may alternate. Because fibrous 
tissue is present all over the body and therefore subject to the in- 
flammatory process of this disease wherever situated, the anatomic dis- 
tribution is widespread and may be classified according to location such 
as panniculitis, abdominal fibrositis, pectoral fibrositis, etc. Fibro- 
sitis in the underlying muscular material of the body is frequently termed 
nyalgia, muscular rheumatism or myofascitis. Periarticular fibrositis 
involves only the periarticular structures of the joint, and is character- 
ized by stiffness and soreness of the joints, usually after periods of 
prolonged rest and on arising in the morning. Periarticular fibrositis 
is frequently mistakenly diagnosed as atrophic arthritis, but again the 
diagnosis is made by exclusion. The distinction between tendinous fibro- 
sitis and tenosynovitis appears to be a rather finely drawn one, based 
purely on the extent of involvement. 
Treatment: Treatment, is divided into two main types, general and 
locals Restis important in the relief of pain but should be confined 
only to the acute stages of the disease following which exercises should 
be gradually instituted. Cold and dampness seem to delay recovery and 
it may be necessary to create a complete change in the patient*s en- 
vironment. Medication is important only in the relief of pain while 
salicylates are the most efficacious drug if administered in adequate 
doses. Elimination of foci of infection is imperative. In cases in 
which fibrositis is generalized, cabinet baths or baths of hot epsom 
salts taken at home are effective in some cases, in association with 
gentle massage to stimulate the vasomotor system and the lymphatic cir- 
culation. Any form of physical therapy which produces relief should 
be utilized and treatment should not be confined to one or more meas- 
ures. This will include diathermy, infrared radiation, hydrotherapy, 
paraffin baths, massage and exercise within the limits of pain. Favor- 
able reports have been given to histamine by iontophoresis and by in- 
jection, as well as histamine cataphoresis. Deep x-ray theray has been 
employed with promising results. 
The orthopedic aspects of low back pain are outlined by Hamsa (9) 
with an interpretation of the significance of the positive signs observed. 
A discussion of some of the conservative measures of treatment of low back pain such as correction of unequal leg length, diathermy, infrared 
radiation, hot packs and external support is included. 
Posture is defined as the relationship of the center of gravity to the 
line of gravity. Normal posture is present when the relationship of the 
center of gravity to the line of gravity is comparable to that of the major- 
ity of individuals. Theoretically this line of gravity rises through or 
slightly anterior to the ankle, through the knee and hip joints, and then 
crossing the sacrolumbar, lumbodorsal and cervicodorsal sections of the 
spine. Under certain conditions as in pregnancy, obesity, muscular weak- 
ness or bone deficiency, the line of gravity is moved posterior to the 
sacroiliac joint and balance of the body is then possible only by excessive 
muscular effort or by accentuating the lumbar lordosis. This produces sec- 
ondary increase in angle of pelvic inclination, a flexed position of the 
hips and dorsal kyphosis. This change of alignment alters the function of 
all systems of the body due to the secondary positions adopted by these 
organs, making possible the simulation of numerous organic changes includ- 
ing peripheral joint changes, but by far the most common condition found 
is strain of the low back structures. 
In a general discussion of the subject of backache built around a 
tabulated outline of the problem Kleinberg (10) emphasizes the importance 
of a detailed history of the onset and course of illness, physical examina- 
tion and pathological conditions in the back. One must bear in mind the 
numerous causes of backache most of which in a given case, can rapidly be 
eliminated by the history and examination. The final diagnosis depends 
upon the correlation of all the facts of the history and the evidence eli- 
cited by the physical examination, first of the special systems and then 
of the tissues of the back, supplemented by the required laboratory aids. 
Once the diagnosis of the cause of the backache has been established, the 
therapeutic program is readily outlined. 
In an article on "Differential Diagnosis of Sciatic Pain" Stuck (11) 
tells.us that pain is a subjective complaint and is variable in severity, 
character and location, thereby rendering interpretation difficult. The 
chronological history should be related to other symptoms and signs in 
order to aid in confirming the diagnosis. 
Sciatic pain is a descriptive term used to localize pain traveling 
downward from the gluteal region into one or both legs. Fifteen types of 
sciatic pain of different causes are described with pertinent historical 
symptoms and signs to make possible a differential diagnosis. Some of the 
most common causes of sciatic pain as given by the author ares 
(1) Sciatic and back pain as a result of fatigue in patients who 
are not accustomed to s trenuous work, 
(2) Hysteria or compensation neuroses. 
(3) Referred sciatic pain. 
(U) Spinal fracture. 
(5) Vascular disease, including Buerger's or Raynaud's, arterio- 
sclerosis and varicose veins. 
(6) Sacroiliac disease. (7) Spinal cord tumors* 
(8) Gunshot wounds of the spine. 
(9) Hypertrophied ligamentum flavum. 
(10) Metastatic tumors of the spine, pelvis, hips and adjacent soft 
tissues. 
(11) Compression fracture of the lumbar spine. 
(12) Causalgia of the lumbosacral plexus. 
(13) Ruptured lumbar intervertebral disc. This is the most common 
cause of sciatic pain, unilateral in type. 
The most significant recent single advance in the differential diagno- 
sis of intervertebral disc has been the correction of the systemic dermatome 
sensory pattern for the lower extremity. 
Moore (12) is of the opinion that; (A) Most cases of low back pain 
with or without radiation can be relieved. (B) All cases, especially the 
ones suspected of having disc protrusions should have a careful orthopedic 
study and analysis before surgery for the removal of a disc protrusion. 
(C) Most cases called "disc protrusion’* do not have a protruded disc. Sym- 
toms are due to mechanical irritation of the nerve roots. (D) Most cases 
of real disc protrusions are secondary to a mechanical or pathologic weak- 
ness of the spine and orthopedic treatment is indicated. (E) Most cases 
can be accurately diagnosed with a careful history, physical examination 
and x-ray studies of the spine. Disc protrusions can be differentiated 
from cases of mechanical root irritation and the site of the lesion can be 
localized with a high degree of accuracy without visualization of the spin- 
al canal. (F) The primary cause of symptoms in most cases is mechanical 
weakness of the spine with increased lumbar lordosis. (G) Most cases can 
be treated with conservative orthopedic measures, (H) Of the cases that 
require surgical exploration, the fifth and fourth interspaces should be 
routinely explored. This should in most cases be followed by a type of 
spinal fusion that corrects lordosis at this segment and prevents the re- 
currence of nerve root irritation, (I) Fusions can be performed only when 
and if a practical technique has been developed that assures bony union in 
a high percentage of cases, (J) The decision for fusion can be made only 
at the time of surgical exploration. 
Symptoms are due to narrowing of the posterior elements of the spine 
with pinching or irritation of tender soft tissues or mechanical compression 
or irritation of nerve roots at or about their emergence through the inter- 
vertebral canals. The causes of nerve root irritation are many. In infancy 
the spine is practically straight. In adolescence the lumbosacral angle is 
about 15 degrees to 18 degrees. In young adult life it normally may approx- 
imate 25 degrees to 35 degrees. From middle age and beyond it may increase 
from U5 degrees to almost 90 degrees depending upon its structure and the 
strain that has been imposed. It is common knowledge that few patients less 
than twenty years of age have ruptured discs. Presumably, this is due to 
the youthful position of the lumbosacral angle and the strength of the struc- 
ture. If this strength and position could be maintained without degenerative 
changes, no symptoms would develop in later life. It is then logical that 
the treatment of low back conditions where lordosis is exaggerated and the 
integrity of the structure has been effected that the lordosis should be 
corrected and the strength of the structure should be restored. In most 
cases it can be accomplished by conservative methods of corrective exercises, 
or in some instances, by the radical method of prop bone graft. In the author’s experience, 60% of patients with clinical findings 
generally considered to be typical of disc protrusion, do not have a 
herniated nucleus pulposus when the spinal canal is explored. The symp- 
toms are due to nerve root irritation or mechanical compression. A 
concealed disc or soft, bulging disc is not the cause, per se, of low 
back or radiating pain. Fusion of the spine of these cases with the 
vertebrae popped wide open have given universal relief from nerve root 
irritation. 
The pathological picture is one of progressive degeneration and 
increase in lumbar lordosis with the advancement of age. In deference 
to Temple Fay and Chamberlain, forward flexion of the spine does not open 
up the posterior portion of the intervertebral space and cause a herniated 
disc to be sucked back into place. Flexion of the spine causes increased 
pressure within the intervertebral disc. At operation the ruptured disc 
has become tense and bulged when the patient's body was flexed to the 
lateral knee-chest position. It is true that the intervertebral disc is 
a buffer and may act as a cushion in absorbing shock but it does not act 
as a compressible elastic medium. The nucleus is a semifluid substance 
composed of 80$ or more of water and follows Paschal's laws. Compress- 
ion forces applied from any direction by flexing, extending or lateral 
flexion of the spine are transmitted1 equally throughout the incompress- 
ible nuclear material to be taken up by the annulus fibrosus fibers that 
are basket-weave in arrangement. Thus, the forces applied to the cart- 
ilage plate of the vertebra above and below the disc are equalized. The 
intervertebral disc is the toughest and most unyielding part of the vert- 
ebral structure. Complete curettement of the intervertebral disc seems 
illogical since it enhances the unpreventable degenerative changes that 
naturally occur with the advancement of age. Treatment should include 
removal of the extruded and loose nuclear material and fusion of the spine 
with prop bone grafts which correct lordosis and relieve nerve root com- 
pression. The results from this type of treatment are encouraging. The 
technique includes the modification of McBride's principle of apophyseal 
graft in conjunction with a "butterfly" type of prop graft between the 
spinous processes. Pictures and illustrations are shown. Poor results 
have been due to poor technique and failure to obtain satisfactory fusion. 
As technique has improved, the results have become proportionately better. 
In discussing "Marie-Strumpe11 Arthritis and the Undiagnosed Low 
Back Patient" Baker (13) states that there is an apparent lack of know- 
ledge of this disease by Medical Corp» officers and the general medical 
profession at large. Many authors have classified Marie-Strumpell or 
rhizomelic spondylitis as a form of atrophic arthritis. This is probably 
a false conception because in the early stage of rhizomelic spondylitis 
there is an increased density of the subchondral bone in contrast to 
atrophy as present in atrophic arthritis. In addition, there is a favor- 
able response of rhizomelic spondylitis to x-ray therapy in contrast to 
the poor response shown to atrophic arthritis. 
Symptoms and Diagnosis: The most consistent early symptom is a 
vague morning backache of a lumbosacral type which, as stated by Herrick 
and Tyson, frequently disturbs the late hours of the patient's rest. This pain is followed by relief with mild activity as the morning pro- 
gresses, only to be followed by the return of pain in the evening after 
the day's activity. The onset most frequently occurs in the sacroiliac 
region, however, there are three common sites of onset; (1) the sacroiliacs, 
(2) the lumbodorsal junction and (3) the cervicodorsal area. The patients 
usually present themselves to the doctor in the third decade of life and 
are most frequently males, however, it is not uncommon for a female to 
have this disease. In addition to low back pain there may be associated 
sciatica and hip pain. If the early signs are in the lumbodorsal area, 
there may be a radicular pain which mimics intercostal neuralgia, pleurisy, 
or cardiac disease and because of the flank pain some of these patients 
are frequently seen in urological consultation. An occasional patient 
will have involvement of the peripheral joints, primarily the hips, knees 
and shoulders accompanied by synovial hypertrophy which makes it difficult 
to differentiate the disease from an atrophic arthritis. It may be that 
this group of patients actually present a mixed type of arthritis. Endo- 
carditis or iritis are frequently present in this group. Temperature 
elevations are rare. During the active phases of the disease the sedimen- 
tation rate is the only laboratory procedure which may be abnormal. 
X-ray Changes: Forestier in reviewing sixteen cases was able to prove 
by reinterpreting roentgenograms taken two, four or even eight years prev- 
iously that sacroiliac changes were already existent and had been over- 
looked. As a rule early calcification and mottled trabeculation can be 
demonstrated in the subchondral bone adjacent to the sacroiliac joints 
with haziness and apparent widening of the joint spaces. Associated with 
these changes are pyknotic areas of increased density particularly in the 
lower poles of the sacroiliac joints. The findings are usually bilateral 
but more definite on one side than the other and in some cases may be con- 
fined to one side. Later the osteosclerosis present in the pyknotic areas 
advances along the subchondral area with destruction of the articular cart- 
ilage and trabeculation across the joint space. As the disease advances 
there is involvement of the joints of the articular facets of the spine and 
oblique films may show haziness and narrowing of these joints. Forestier 
differentiates between the osteophytes seen and non-ankylosing vertebral 
ossifications and ankylosing ossifications, which he calls syndesmophytes. 
This tern means growths from the ligament in opposition to osteophytes, 
which means growths from the bone. 
Treatment: The x-ray treatment as recommended by Hemphill and Reeves 
is reviewed and the efficacy of this measure in alleviating pain is stressed 
before the onset of other measures of treatment. As soon as the patient 
has experienced sufficient alleviation of pain following x-ray therapy 
attempted correction of deformities is started. A Gatch bed equipped with 
a sponge rubber mattress and a fracture board sewed in to conform to the 
Gatch bed is used for hyperextension in association with traction as required. 
A picture is shown of an apparatus which makes it possible to control the 
force used in obtaining hyperextension and to direct it to correcting the 
dorsal curve and developing the upper sacrospinalis muscle bundles. A 
picture of an operating table head rest which is adjustable in all direct- 
ions is shown and which has attached shoulder supports to be utilized for 
the purpose of treating patients with deformities as a result of Marie- 
Strumpell’s arthritis. In the treatment of these patients a brace to 
relieve pain and give further correction when the patient is ambulatory is essential. The brace should incorporate an active force for main- 
tenance of proper posture and at the same time be sufficiently comfortable 
to be tolerated. A picture of a suitable brace meeting these require- 
ments is given. 
Home therapy consists of continued use of the hyperextension bed, 
wearing of the described brace, continued corrective exercises, main- 
tenance of an adequate diet and limitation of activity in keeping with 
the patient’s disability. Rest periods of at least thirty minutes are 
recommended twice daily, and, when available, recreational and vocational 
guidance are invaluable as a part of the educational program. 
The commonest factors entering into the etiology of back pain as they 
have been found in Bach’s (ll±) experience ares 1. Myositis secondary to 
unusual exposure; to a sudden strain or trauma; to poor posture; to arth- 
ritis of the lower spine and sacroiliac joints; to backward slipping of 
the sacrum at the lumbosacral articulation. 2. Protrusions of the inter- 
vertebral discs. 3. Congenital malformations of the lower back in the 
neighborhood of the lumbosacral articulation, k• New bone formation 
occurring in osteoarthritis. 5. Pathologic lesions in the pelvis and 
kidney that cause referred pain in the back. 
The etiological factors of backache are discussed from the point of 
view of pain in the upper back, pain in the middle portion of the back 
and finally pain in the lower back. 
Upper Back Pains The commonest cause is an osteo-arthritis involv- 
ing the cervical vertebrae, especially if the initial symptoms appear when 
the patient is over forty years of age. The exact mechanism of production 
of pain in these patients is not well understood. The most commonly 
accepted methods of treatment of osteoarthritis in the upper back are the 
same as encountered with this disease in any other part of the body. Spec- 
ial methods of treatment include the use of a Thomas collar or continued 
cervical traction by use of a Sayre sling. 
Middle Back Pain: Pain as a rule is due to osteo-arthritis, rheuma- 
toid arthritis, or myositis secondary to sudden exposure to cold or strain, 
while in rare instances it may be due to the presence of tumors* Consid- 
eration in diagnosis must always be given to the presence of pathology 
in the kidneys, bladder, prostrate, adrenals, malignant new growths with 
metastasis in the lower spine; focal infections anywhere in the body, but 
particularly in the genito-urinary tract. Diagnosis is arrived at by 
consideration of history, physical examination and x-ray findings* The 
general practitioner is urged to make use of special consultations for 
these patients where required. 
Low Back Pain: A review of the anatomy, pathology, physical find- 
ings, symptoms and the diagnosis of protrusions of pathological lesions 
of the intervertebral disc is given which in general conforms to the pre- 
sent consensus of opinion as expressed in medical literature. The conser- 
vative management of these patients is emphasized with the statement that 
most of them get well if they are put to bed, immobilized, given heat, 
massage and other therapy used in sciatica. After careful conservative management of the patient and there is no improvement, the use of an 
orthopedic or neurosurgical or other allied specialist is recommended. 
Shortening of a Leg: Leg shortening causing tilting of the pelvis 
may occasionally be the cause of pain in the lower back. This condition, 
unfortunately, is usually overlooked. A difference of even l/Uth inch 
should be considered as a possible cause of trouble if the patient is 
complaining of pain in the lower back, since tilting of the pelvis may 
produce strain in the sacroiliac joints and eventually lead to sciatic 
pain. 
Pain in the Coccyx or Coccygodynia: Is usually caused by trauma 
which causes a dull ache that is aggravated by sitting on hard surfaces 
Or rising from the sitting position. Rectal examination reveals tender- 
ness over the center of the coccyx with forward tilting at a sharp angle 
of the lower part of the coccyx. Treatment of these cases, as a rule, 
is unsatisfactory, but should include hot baths, sitz baths and various 
analgesics and massage of the pelvic muscles with the finger in the rec- 
tum and as a last resort, removal of the lower end of the coccyx at the 
site of the apparent fracture. Surgical treatment of these patients is 
often times unsatisfactory. 
Congenital Anomalies: The most common abnormalities of the back 
are spina bifida, sacralization of the transverse process of the fifth 
lumbar vertebra, forward or backward dislocation of the sacrum on the 
fifth lumbar vertebra and congenital abnormalities in the articular 
facets of the fifth lumbar vertebra. The presence of these anomalies is 
the cause of pain in only £0$ of patients. The attending general prac- 
titioner should refer these patients to an orthopedic surgeon for advice 
and treatment. 
Lumbosacral Diseases The lumbosacral Joint is the weakest Joint 
in the entire spine and because of the intimate association of the liga- 
ments of this Joint which also covers the sacroiliac Joints and the nerves 
running down over the Joints, it is usually quite difficult to make a clear- 
cut differential diagnosis. The most reliable sign is direct pressure of 
pain over the lumbosacral angle. The differential diagnosis is not extreme! 
important because the treatment is the same in either case. 
The differential diagnosis between lumbago, myositis, fibrositis and 
neuritis as factors in pain in the back cannot always be differentiated 
in any given case. The treatment is the same and, according to the sever- 
ity of the case, one should employ rest of various degrees, salicylates 
in large doses, heat and massage, if tolerated. If satisfactory results 
are not obtained the patient should be given a course of x-ray therapy. 
If relief is still not obtained, absolute rest in bed for a period of at 
least six weeks, with or without a plaster cast on the back or a back sup- 
port in the form of a brace or rigid corset is indicated. 
Sciatica is a somewhat vague term used to describe a symptom complex 
distinguished by the fact that the patient suffers from pain in the back 
associated with a reflex pain that shows a marked tendency to run down the 
leg, along the distribution of the sciatic nerve. Sciatica is almost always due to a pathological process located in either the sacroiliac 
or the lumbar joints or in their associated ligaments. The pathological 
processes which are most commonly found are trauma, infections, metabolic 
changes and malignancy. In typical cases of sciatica, the following positive 
physical findings are presents 1. A tilting of the upper part of the body 
toward one side or the other with a limitation of ability for forward flex- 
ion and lateral flexion. 2. Tenderness over the sacroiliac area of the 
affected side and in the sacrotuberous ligaments as in the lumbar joint, 
located about one inch from the midline in the angle between the ilium 
and the sacrum. 3* Limitation of straight leg raising. 1*. Positive 
Gaenslen's test. 5. Positive Ober test. 6. Roentgenological changes 
with the patient in the standing, recumbent or lateral position. 
After an accurate differential diagnosis has been made in these 
patients, treatment should include rest in bed for a period of from three 
to six weeks in a comfortable position, large doses of vitamin B, salicy- 
lates, gentle massage of the hips daily or at least three times a week, 
deep injection of novocaine, and finally, as a last resort, it may be con- 
sidered wise for a consulting orthopedic surgeon to perform an Ober opera- 
tion. 
This article is a write-up of a clinical conference dictated by 
Dr. Americo Nunziata (l£) on the subject of backache with and without 
sciatic radiation. A generalized discussion is presented of the mechan- 
ism of pain and common etiological factors of backache with and without 
sciatica, including arthritis, fibresitis, hypertrophic ligamentum flavum, 
sciatic neuritis, spinal cord tumors, spondylolisthesis, rupture of an 
intervertebral disc, secondary to degeneration of the disc, and postural 
backache. The pathological interpretation of diagnostic signs in associa- 
tion with the examination of a patient with backache and radicular pain 
is ably presented. Elevated spinal protein is considered helpful in the 
diagnosis of spinal cord tumors. Because of the high incidence of false 
negative myelographic studies of herniated intervertebral discs, a myelo- 
graphic study of the spine is reserved for those patients suspected of 
having spinal cord tumors. 
”Backache, Examination and Treatment” by Geckeler (16) is another 
article dealing with the history, physical examination and treatment of 
backache. Under history the author includes significant questions to be 
asked the patient with interpretation of the patient's answers. Physical 
examination includes an interpretation of the pathological signs observed 
in the patient. A plan of treatment of common back conditions, such as 
strain, sprain, congenital defects and anomalies, acute arthritis, chronic 
arthritis, degenerative changes, fascitis and backache with referred pain 
and also backache as a referred symptom is given. Conservative treatment 
outlined in the article is in general agreement with other opinions in the 
literature at the present time. 
In contradistinction to pain caused by herniated disc material com- 
pressing a nerve root, West (17) believes that a**throgenic sciatica is 
produced by irritation of the funicular segment of one or more nerve roots 
where these lie in close proximity to the arthritic apophyseal joints, 
with associated vascular changes of congestion and swelling. The usual primary cause of this apophyseal arthritis is degeneration of the cor- 
responding intervertebral disc. As the disc further degenerates, the 
vertebral bodies approximate one another, throwing the apophyseal articu- 
lations into mal-alignment so that progressive arthritic changes develop 
in them. 
Diagnosis: A clear-cut case of arthrogenic sciatica occurs in a 
patient of forty years or older who has lumbosacral arthritis as evidenced 
by chronic low back pain with limitation of movement. Excessive exercise 
aggravates the pain. 
Treatments No patient should be operated on who responds to conser- 
vative treatment. If there is any doubt about the origin of the sciatica, 
the patient is referred to a neurosurgeon for opinion. Eleven of this 
series of $2 patients have undergone laminectomy and exploration of the 
nerve roots. In six of these cases these procedures were followed by 
fusion at the same operation, and all patients were relieved of their 
sciatica. In only one case was herniation of disc material found. The 
other five patients had the fusion performed at a second operation. In 
two of these cases the discs were normal, two showed obvious degenera- 
tion and one other had a herniated nucleus pulposus. 
At operation fusion from the second lumbar body to the sacrum is 
carried out. Two curved tibial grafts have been used in most of these 
patients, shaped so as to fit the lumbosacral curve as accurately as possi- 
ble, and these have been reinforced by spongy bone and fine shavings. In 
those cases fused with iliac grafts only the percentage of failure of fusion 
has been higher. 
Results; Listed below are the results in 37 cases in which more 
than eight months have elapsed since operation: 
Table I. 
Type of Graft 
Combined 
Fusion after 
Tibial 
Iliac 
Combined Tibial 
Laminectomy 
Previous 
Results 
Graft 
Graft 
and Iliac Grafts 
and Fusion 
Laminectomy 
Good (26) 
21 
k 
1 
h 
3 
Fair ( 7) 
1 
1 
2 
— 
Bad ( ii) 
1 
3 
— 
—- 
Total (37) 
27 
8 
2 
6 
3 
Twenty-six of the cases have resulted in complete and lasting relief 
from symptoms. Of the seven fair results only one man has any sciatica, 
in which case a limited fusion between the fifth lumbar vertebra and the 
sacrum was performed by iliac bone. Among the four failures, one woman 
died of paralytic ileus four days after operation. In the other three 
fusion was done with iliac graft. In two cases the bone has been absorbed 
and fusion has not occurred. One patient has since had a further operation, 
and practically no bone was found, and the remaining patient is waiting 
for re-operation. According to Kaplan (18) the early diagnosis of a neoplasm of the 
cauda equina is almost entirely a laboratory procedure. If a patient 
with a "sciatic syndrome" is refractory to treatment and the etiology 
is obscure, then one must make full use of such laboratory procedures 
as the study of the spinal fluid and myelogram, to determine whether or 
not there is need for surgical therapy. 
The author reports a case of neurofibroma of the cauda equina 
causing recurrent attacks of sciatica over a twenty year period of time. 
The history was characterized by attacks of pain lasting about U8 hours 
followed by relief of pain for approximately four to six weeks. Nine 
years prior to removal, the attacks became more severe and occurred 
every three days, during which time the patient was unable to walk, bend 
or bear any weight on the right leg. At no time were there any sensory 
or sphincter disturbances. There was a period of about one year when the 
patient was free of pain. Increase in symptoms one and one-half years 
prior to removal of this neurofibroma caused hospital admission. At this 
time the patient showed a halting gait, limitation in spine motion, spas- 
ticity of the lumbar muscles and absent knee and ankle jerks, with nega- 
tive x-ray films of the spine. Spinal fluid was clear and colorless* and 
there was no subarachnoid block, but the total protein was 200 mg, per cent. 
After several days of hospitalization symptomatic relief of pain was ob- 
tained and the patient was discharged from the hospital without proper 
follow-up of the elevated spinal protein. In September 19U7* the patient 
was seriously incapacitated as a result of his recurring attacks of pain 
and he was readmitted to the hospital. At this time there was a loss of 
lumbar curve with marked spasm of the overlying muscle and the patient 
was unable to walk and hardly able to stand. The patellar and Achilles 
reflexes were absent. Jugular compression test reproduced the pain with 
radiation down the right leg, Sensoiy examination to all modalities was 
normal. There was no sphincter disturbance. On October 6, 19U7> a lam- 
inectomy was performed from lumbar three to lumbar five vertebrae inclu- 
sive which revealed an encapsulated, olive-shaped tumor intradurally 
attached to the fourth lumbar root on the right side. The tumor and nerve 
root were resected and microscopic study showed a typical neurofibroma. 
The postoperative course was uneventful except for a moderate amount of 
abdominal distention. The patient was completely free of pain. Had this 
patient been properly worked up, a diagnosis most likely would have been 
made at an earlier date. 
Backache in women according to Barns (19) may be due to abnormali- 
ties of the female genital organs, such as retroversion, prolapse of the 
uterus, inflammation of the uterus, or its appendages, pelvic cellular 
tissue or pelvic peritoneum; and neoplasms of the uterus or its append- 
ages. It is the acquired type of retroversion that may cause backache. 
It is less frequently due to the mobile acquired retroversion as seen 
in the postpartum patient than to the fixed type. Backache may be assoc- 
iated with cervicitis and endometritis. Neoplasms of the genital tract 
may be associated with backache. Backache in the lumbosacral area in 
these female conditions is caused by an increase in tension in the poster- 
ior segment of the pelvic floor. It must be strongly emphasized that 
such lesions may exist without producing an increase in tension in the 
posterior segment of the pelvic floor and in these cases is not the cause 
of the accompanying backache. The lack of appreciation of this fact accounts for so many patients having their backache attributed to a 
pelvic lesion whereas it is in fact due to an undiagnosed orthopedic 
cause. In order to treat the women with this disabling symptom we 
must first determine which of the many causes is responsible for the 
symptom in her particular case. This requires full examination of the 
spine, including x-ray of the pelvis and very often the help of the 
orthopedic surgeon, urologist or physiotherapist. 
Moore and Cook (20) believe that the unstable spine, with or with- 
out ruptured disc is an orthopedic problem that requires intensive study 
for its proper evaluation. Most cases can and should be treated conser- 
vatively but some require operation. Conservative treatment is not con- 
servative if it means that an individual who could be relieved by surgery 
is condemned to a life of semi-invalidism. In these cases operation is 
the most conservative type of treatment. Excellent results from surgery 
are difficult. They require excellent surgical judgment, an excellent 
operation, as well as excellent follow-up care. A movie was shown in 
association with this paper and demonstrates the prop graft operation 
devised by the author for surgical fusion of the unstable spine. Mental, 
physical and vocational rehabilitation is a part of the surgeon*s total 
responsibility. 
The authors believe an exaggerated lordosis is primarily responsible 
for the development of symptoms of back pain with or without sciatica. 
The back weakness predisposes to a rupture of the intervertebral disc 
with herniation of the nucleus pulposus. Operation to remove the disc 
does not cure the back weakness and, therefore, does not relieve the 
patient of pain in all cases. Reference is made to a recent survey of 
an insurance company which shows that 60$ of patients operated on for 
rupture of the intervertebral disc had postoperative pain and disability. 
This finding coincides with the author’s study which shows that 60$ of 
the patients with typical symptoms do not have ruptured discs. The symp- 
toms in these cases are due to narrowing of the intervertebral space 
which results in compression of the nerve root at the intervertebral 
foramen. For relief the spine must be blocked open or propped with a 
bone graft that holds it in position and permanently protects the root 
from any further pressure. 
In an article on "The Painful Coccyx" Thiele (21) discusses the 
history, etiology, physical findings, diagnosis and treatment. He re- 
ports the results in U*2 cases. Pain may be localized in the coccyx 
itself as a result of fracture or other direct injury, but it is usually 
not in the bony parts. Instead it is usually located in the sacrococcygeal 
joint or in the muscles which are inserted into the lateral borders of 
the lower sacrum and coccyx, namely, gluteus maximus, levator ani and 
coccygeus muscles. Coccygodynia is not due to rheumatism or neuralgia. 
History: The chief complaint is one of pain or aching generally 
localized to the region of the coccyx or to the muscles ana other soft 
tissues to one or both sides of the coccyx within a distance of about 
two inches. The exciting causes will include a prolonged sitting, falls 
on the buttocks, bumps, childbirth or ignorance of any cause. The sever- 
ity of pain is in proportion to the length of time that sitting is con- 
tinued without interruption. The most severe pain is experienced as the patient arises from the sitting position. Symptoms of rectal or anorectal 
disease are often present. Frequently there is associated pain in the 
upper portion of the gluteal region and/or down the posterior aspect of 
the thigh along the course of the sciatic nerve. If acute trauma has 
been the existing factor, muscle spasm occurs at once and the onset of 
pain is sudden; if the trauma is prolonged as in long continued riding 
or sitting, the onset of pain is gradual. It is also gradual in those 
cases in which spasm and pain are secondary to focal infection in the 
anus, urethra, prostate, seminal vesicles or cervix uteri. 
Etiology: In this series of cases etiological factors were deter- 
mined to include anal infection in 89; direct trauma in 28; prolonged 
trauma due to long automobile rides or train rides 10; undetermined 
causes 10; prostatic infection 2; epididymitis 1; endocervicitis 1; and 
spinal cord tumor 1. 
Physical Findings; Observation will reveal that patients sit down 
slowly and carefully, oftentimes close to the edge of the chair, with 
frequent shifting of weight from one buttock to the other# It is painful 
for the patient to arise from a sitting position* A large majority of 
these patients habitually sit in ppor posture with the back convex and 
the lower sacrum and coccyx in contact with the chair, instead of sitting 
up straight with normal lumbosacral concavity* This is a causative factor 
in itself* 
The normal coccyx has a rotation arc of 30 degrees with the sacrum, 
and may be moved laterally for a distance of about one centimeter from 
the raidline. A pressure of 10 to l£ pounds against the tip of the coccyx 
with the thumb causes no pain or tenderness in the normal individual. 
In performing a rectal examination, the gloved finger should be in- 
serted the full finger-length and pressure made against the posterior 
rectal wall, the thumb being placed on the coccyx externally. Palpation 
of the coccyx between the thumb and forefinger is performed first and 
exquisite tenderness should cause one to suspect fracture. The examin- 
ing finger should then be moved laterally, anteriorly and finally 
medially back under the symphysis pubis. As the examining finger is 
passed through this arc the gluteus rnaximus, levator and coccygeus 
muscles are palpated. When coccygodynia is present, spastic fascicles 
of the involved muscles will be felt, unless all of the muscle is in 
spasticity and then a broad, tight, flat band will be palpated. Ano- 
scopic examination should be performed to reveal the presence of any 
anal infection. In the male the state of the prostate and seminal 
vesicles should be determined, and in the female the cervix should be 
visualized* 
Diagnosis; The diagnosis of coccygodynia involves the following 
factors: Pain in the region of the coccyx, either alone or associated 
with sacral backacne, pain in the superior gluteal region and down the 
course of the sciatic nerve* The pain is definitely and characteris- 
tically made worse by continued sitting, and is characteristically worst 
of all during the act of arising from the sitting position. Tenderness on pressure against the tip of the coccyx may or may not be present, and 
is more often absent than present. Increased pain during the act of 
arising is due to added contraction of the levatores ani and of the inner 
fibers of the gluteus maximus with resultant increased traction on the 
coccyx producing stress on the sacrococcygeal joint. If coccygodynia has 
been accompanied by pain in the superior gluteal region or along the course 
of the sciatic nerve, spasm and tenderness of the piriformis muscle on 
the affected side will be found. Spasm of the piriformis muscles does not 
cause coccygodynia, Coccygodynia must be differentiated from the severe 
and sometimes lancinating pain accompanying acute anal ulcer. The differ- 
ential diagnostic point is that with an anal ulcer, the sitting position 
tends to relieve rather than to exacerbate the pain. 
Treatment! The treatment of coccygodynia consists of massage of the 
spastic muscles attached to the sides of the coccyx, and of medical treat- 
ment of and/or surgical removal of focal infection. One cannot too strongly 
condemn removal of the coccyx if the intention of the surgeon is to cure 
coccygodynia. 
Salem (22) reviews the detailed anatomy of the intervertebral fora- 
men including its contents in an article on "Low Back Pain Due to Narrow- 
ing of the Intervertebral Foramen," Special attention is paid to the 
anatomical consideration of the posterior primary foramen. Three case 
reports are in this article including one case of low back pain due to 
nerve root irritation caused by exostotic narrowing of the interverte- 
bral foramen with subsequent relief by removal of compressing exostoses 
and resection of the involved intervertebral joint. Another case of nar- 
rowing of the intervertebral foramen, secondary to rotation scoliosis, 
is recounted with subsequent relief after removal of the associated inter- 
vertebral joint, A third case of a decreased intervertebral foramen 
which was manipulated is included in this article, the narrowed foramen 
being due in this case to extreme subluxation of the intervertebral joint. 
It is essential that detal led x-ray study be made in these cases of 
low back pain in order to determine exactly the presence of a decreased 
intervertebral foramen. It is advisable to consider the intervertebral 
foramina as a source of low back pain and at operation to expose the for- 
amina of the involved area in order to remove any irapingment of the con- 
tained structures. 
Cleveland, Bosworth and Thompson (23) have called our attention again 
to the fact that surgical fusion of the spine as regards mortality and 
complications has proved to be of minor importance, while failure of accom- 
plishment of successful arthrodesis of a selected series of vertebrae in 
the lumbosacral region has proven to be of major importance. 
In this series of cases, 6U7 operative procedures were carried out 
on £9U patients with an average postoperative follow-up period of 3h 
months, Pseudarthroses developed in 119 instances or 20$ of the operative 
cases. One thousand three hundred and twenty-nine spinal intervals were 
bridged and pseudarthrosis occurred at 161 intervals among these patients, 
or an instance of failure of 12,1$ The incidence of pseudoarthrosis increased with the addition of added numbers of vertebral segments. 
There was 3»h% of failure of fusion when only the lumbosacral joint was 
involved; 1?,U$ when the fusion extended from L-U to S-l; and 33>3% of 
pseudoarthrosis occurred as additional segments were added. As the 
area of fusion is lengthened there is an increase in the incidence of 
pseudoarthrosis, but a marked decrease in the number of patients with 
solid fusion who are unrelieved of their symptoms. It is essential in 
determining the incidence of pseudoarthrosis to make roentgenograms of 
front and side bending of the lumbar spine. This will give view of a 
biplane dimension. Using this as a diagnostic criteria, 21$ of the 
patients were shown to have pseudoarthrosis while only 11.8$ were diag- 
nosed as having failure of fusion by clinical judgment and flat roent- 
genograms. 
Of the typical posterior herniations of the intervertebral disc, 
pseudarthrosis developed in 11.14$; this low percentage is attributable 
to the-universal use of the clothespin graft, plus quantities of addit- 
ional bone. Pseudarthrosis developed in 22,5$ of those patients operated 
for lumbosacral strain; 16.1$ of patients operated for tuberculosis; 
23.2$ of patients operated for spondylolisthesis; 29.7$ of patients 
operated for arthritis of the spine; and 25$ of failure in all others 
who were brought to surgery for spinal fusion for such conditions as 
foreign body, fracture of the lamina, hemivertebra, or scoliosis. 
In reviewing this series of pseudarthrosis there appears to be a 
definite factor as the cause of pseudarthrosis in all but ten cases. 
In thirteen instances it was attributable to inadequate amount of bone. 
In five instances the pseudarthrosis was due to the use of solid, heavy 
tibial bone without support of iliac bone or other fine strip grafts. 
Infection, draining sinuses, hematoma, etc. occurred in ten instances. 
In five instances solid spine fusion had been fractured and at operation 
it was revealed the spinous process was separated from the underlying 
laminae at the upper end of the clothespin graft in two cases, and in 
three instances the fusion had been broken directly across. Crossing 
of previous laminal defects seemed to be the basis of pseudarthrosis in 
ten instances. 
The new type of operative procedure was used for repair of the 
more difficult cases of pseudarthrosis. This repair consists essenti- 
ally in denuding the laminae and the lateral margins of the articular 
processes, with extension of the dissection to the bases of the trans- 
verse processes on one side only. The medial portion of the trans- 
verse process is likewise denuded. A thin, wide flap is removed from 
the outer cortex of the ilium and implanted vertically on the trans- 
verse processes. Iliac strips are then placed over the denuded poster- 
ior elements of the involved vertebrae themselves; the angle between the 
implanted massive iliac graft and the mid-line being filled in with 
additional bone. 
Brav, Molter and Newcomb (2k) report a detailed and exhaustive 
survey of the measurements of 500 roentgenograms with special refer- 
ence to the narrow disc and lower lumbar displacement. In the total series a narrow fifth lumbar disc was noted in 26.posterior dis- 
placement of the fifth lumbar was present in 10.2; anterior displace- 
ment of the fifth lumbar was present in 5% and there was displacement 
of the fourth lumbar vertebra in 3%, There was little difference in 
the 181 cases in which these changes were noted as to the presence of 
back and leg pain. As to physical signs the alteration in leg reflexes, 
limitation of straight leg raising and body tilt on forward bending 
in patients with altered x-ray findings of the fourth and fifth lumbar 
vertebrae were not significantly different from a control group of 319 
cases without these changes. Except for the incidence of arthritis 
there was practically no difference in the clinical diagnosis of pat- 
ients with altered changes of the fourth and fifth lumbar vertebrae 
and their interspaces than a control group of 319 cases without these 
changes. A study of the groups of patients with back pain alone, with 
associated leg pain and with neither of these complaints reveals no 
significant difference in the incidence of lower lumbar displacement in 
the symptom-free group. Posterior displacement of the fifth lumbar vert- 
ebra is apparently a definite entity and is not due entirely to diff- 
erence in anteroposterior diameters of the fifth lumbar vertebra and 
the sacrum, although in about 20% this is apparently the reason for 
the appearance on the roentgenogram. It is possible that in cases of 
posterior displacement, there is secondary atrophy of the anterior 
edge of the sacrum which decreased the anteroposterior diameter of the 
first sacral segment. Anterior displacement of the fifth lumbar 
vertebra is usually associated with a defect in the interarticular 
portion of the vertebra and in at least k0% of the cases there is anter- 
ior lipping of the sacrum which increases the anteroposterior diameter 
of the first sacral segment. In cases of herniated nucleus pulposus 
or posterior disc protrusion, the incidence of narrowed fifth lumbar 
disc or lower lumbar displacement is not significantly greater than in 
the remainder of the series. Narrow disc on the roentgenogram cannot 
be considered clinical evidence of posterior disc protrusion. Narrowed 
fifth lumbar disc and displacement of the lower lumbar vertebrae are 
clinically significant only in that these conditions place strain on 
the already mechanically vulnerable lumbosacral joint. The weight of 
evidence seems to indicate that in most instances narrow fifth lumbar 
disc and lower lumbar displacement are in themselves not the cause of 
low back and sciatic pain. As is true in the case of transitional ver- 
tebrae and other lumbosacral anomalies, the presence or absence of back 
or leg pain depends almost entirely upon the integrity of the surround- 
ing muscular and ligamentous structures. So long as these structures 
are intact, the patient may be symptom-free. YThen they are no longer 
able to compensate for the abnormal mechanical strain, pain may occur 
because of tension on muscle and ligamentous attachments, degenerative 
arthritic changes in the articular facets or actual pressure on the 
spinal nerves at some point in the region of the deranged lumbosacral 
articulation. 
Little reports a case of Calve*s disease of the spine in a 
four year old boy with the past history, present status and x-ray exam- 
ination. The chief complaint on admission was deviation of the head 
to one side and with an inclination to hunch his shoulders in a peculiar manner when looking upwards. X-rays showed an unusual def- 
ormity in the upper thoracic region and further pictures showed this to 
be probably due to Calve's disease of the spine with a marked collapse 
of the fifth dorsal vertebra associated with widening of the inter- 
vertebral disc space. There was a normal blood chemistry. 
Mes (26) describes the surgical technique of lumbosacro-iliac 
arthrodesis. The operation is performed through an incision lying 
parallel to the last four lumbar spines and one inch lateral to them, 
sweeping distally across the posterosuperior iliac spine out laterally 
to end over the gluteal muscles. The essential component of the opera- 
tion is to swing the incompletely osteotomized posterior iliac crest, 
including the posterior iliac spine over toward the midline to lie in 
apposition to the lower lumbar spines after surgical resection of the 
paraspinal muscles. The graft is held in apposition to the lumbar spines 
and laminae by use of chro»ic catgut or kangaroo tendon and the graft 
should be reinforced according to the Hibbs* technique. After osteoto- 
mizing the graft and before swinging it medially to place it into the 
prepared bed, the superior dorsal portion of the sacroiliac joint is re- 
sected in order to ensure a smooth floor for the bone graft. This opera- 
tion is stated to be easy to perform and should have a better chance of 
bony union because of the retention of a part of the blood supply of the 
graft itself. 
According to Turner (2?) the traumatic type of low back pain is 
produced by too much tension or pull on the ligaments and muscles about 
the lumbar and lumbosacral articulations, resulting in tears in and 
about the origin and insertion of these muscles and ligaments. Treat- 
ment recommended is intracaudal (through the sacral foramen) injections 
slowly of 3 - 5 cc's triesthesia by using a special caudal needle custo- 
marily employed in caudal anesthesia in obstetrics. Following the inject- 
ion the patient is carried through a normal range of lumbosacral motion. 
Novocaine and oil is used to prolong the action of the anesthetic agent 
rather than novocaine and saline. Injections are given from five to 
seven days apart and do not exceed three in number. The particular 
patients the author selects for treatment of this type are those asso- 
ciated with strain of the low back with sciatic nerve radiation or with 
radiation down the leg or into the hip joint. Treatment has been em- 
ployed over a period of seven years and no complications observed. Con- 
clusion is drawn that triesthesia relieves pain during period of healing 
of torn ligaments. No statistical analysis is given and opinion is 
based on author's clinical experience in the management of these patients. 
Roche (28) reports an unusual case of bilateral fractures involv- 
ing the isthmuses on both sides of the neural arch of the third lumbar 
vertebra secondary to a jeep accident. Photographs of the fracture are 
shown as well as photographs showing union of these fractures. This 
extremely rare condition was not noted in a series of 823 cases encount- 
ered in the Mayo Clinic from 193£ to 1939* inclusive. 
The most lateral protrusion of a prolapsed intervertebral disc is 
termed subarticular prolapse by Hirsch (29). The table listed below 
shows the results of 23 cases in which complete or partial facetectoiqy was performed. Only four of these had total facetectomies. 
Table 3 
Patients free 
from pain in 
Patients free 
Patients free 
Patients 
Number of 
both back and 
from pain in 
from pain in 
enabled 
Operations 
legs 
back 
legs 
to work 
23 
11 
13 
11 
16 
Three of the four cases who had total facetectomies are completely 
cured and free from pain, which suggests that secondary changes do 
occur after partial facetectomy in the operated joints. Of the patients 
included in this series, twenty had definite neurological signs, seven- 
teen had negative rayelographs and at operation fifteen disc prolapses 
were excised, nerve root compression being due to osteophytes in two 
cases. Twelve of the herniated discs were of the subarticular type. The 
table listed above clearly shows the poor results from this procedure. 
On the other hand, failure to look for a subarticular prolapse before 
spinal fusion may result in the burial of a prolapsed disc and this may 
be considered one of the causes of long-standing pain and discomfort. 
In conclusion the author considers that a more radical treatment, facet- 
ectomy, with subsequent fusion, is probably the treatment of choice. 
The results of the examination of 100 lumbar specimens, £00 inter- 
vertebral discs and 1000 intervertebral joints are given in this excellent 
article by Friberg (30), The lumbar spines were removed together with 
the sacrum; the sacrum was fixed in a vise and as soon as possible after 
death the specimens were flexed and extended without forcing and were ro- 
entgenographed in various positions of flexion and extension. After a 
short period of formalin fixation the discs were cut horizontally and 
macrophotographed. The intervertebral joints were removed separately 
and decalcified, and sections were cut from all spaces in order to study 
the relation between disc and joint changes. The investigations have not 
yet been completed. 
As the age increased the amount of fluid in the nucleus decreases, 
fibrosis increases and the borderline between the disc and the annulus 
becomes less distinct. This can be considered to be a natural aging 
process, but degeneration unquestionably occurs where fissure formation 
is found in the annulus. 
In the upper lunibar disc degeneration showed in part a concentric 
arrangement; fissure formation being observed all around the disc* In 
the lower two lumbar discs the degeneration is situated mainly in the 
posterior portion and had a special form* Usually a sagittal path was 
seen going from the nucleus dorsally to the posterior longitudinal 
ligament, running out on both sides in the form of a !,T" and often 
extending to a point slightly lateral to the intervertebral foramen* 
Other authors have pointed out that disc degeneration in the dorsal 
spine occurs in the anterior portion of the disc due to the increased 
pressure over the anterior rataer than the posterior portion of the 
annulus * In this survey disc degeneration was found in the backs of 32 cases 
and disc prolapse in 11 discs. Thus, it may be concluded that disc degen- 
eration was more common and in cases where prolapse was observed, extensive 
degenerative changes were also present. In all cases where a disc showed 
roentgenological instability (posterior displacement) without other roent- 
genological indication of disc degeneration, reduction in the height of the 
disc, osteophytes and sclerosis of the vertebral bodies, fairly widespread 
fissure formation was nevertheless present in the annulus, especially pos- 
teriorly, Instability may thus be said to be an early clinical sign, but 
it implies the presence of advanced changes in the disc. 
Exploratory laminectomy should be performed with caution because of 
the frequency of incapacitating backache postoperatively, Where instability 
of the lumbar spine can be demonstrated without evidence of disc prolapse, 
but only due to disc degeneration, increased incidences of lumbosacral fu- 
sion is recommended. Fusion of these lumbar vertebrae where instability 
exists would prevent several years of constant or recurring backache of 
these patients. This is a natural process which nature performs to arrest 
pain but sequence of events is too slow. 
Parnell and Moore (31) present the results of U3 cases of low back pain 
treated by low spinal fusion, including the lumbosacral joint. Excellent 
results were obtained in sixteen cases, satisfactory in twenty and poor in 
seven. With few exceptions all patients operated on had demonstrable x-ray 
lesions. The operative technique was primarily a Kibbs fusion in associa- 
tion with screw fixation of the lumbosacral articular facets. In all cases 
the incision was a curved median longitudinal one which afforded surgical 
access to the posterior spine and posterior iliac crest for purposes of 
obtaining bone for grafting. As soon as the patients were able to stand 
comfortably postoperatively, a plaster cast was applied from the nipple line 
to the symphysis pubis in front and from the inferior angles of the scapula 
to the lower portion of the sacrum posteriorly. They were discharged from 
the hospital at this time and allowed to return to their homes and resume 
normal work as soon as possible. All cases of poor results were in veteran 
patients* Details of the management of the postoperative course of these 
patients is not included in this article and there is no analysis of the 
causes of poor results. The follow-up time, or method of follow-up of these 
patients is not included. 
A series of 68 successive patients who underwent operations for rup- 
tured intervertebral discs has been analyzed by Bradford (32) in an effort 
to determine the relative value of the accepted diagnostic signs. Sixty- 
one of the 68 patients explored for herniation of the intervertebral disc 
were found to have this condition or a percentage of 89.7$ correct diagnosis. 
Sixty-one per cent were found on the right and 39$ on the left. Forty-six 
proved herniations were at the lumbosacral space and only thirteen proved 
herniations occurred at the fourth lumbar space with only two herniations 
occurring atlhe L-3 disc level. Appraisal of the signs observed was divided 
into general signs and root signs. General Signs: Coughing and sneezing were recorded as increasing 
root pain in 86$ of the negative explorations and only 79$ of the posi- 
tive ones. The incidence of injury is higher in the negative than in 
the proved cases. Jugular compression increased radiating pain in £l$ 
of positive cases and 29$ of negative cases. Reproduction of pain by 
paravertebral pressure favored the proven lesion in the ratio of S9ih3f 
and sciatic nerve stretching favored the positive group as 90:71. 
Sciatic scoliosis and reduced lumbar lordosis gave ratios, positive to 
negative exploration of £1:29 and 80:£7# 
Root Signs: Sensory changes were helpful in 61$ of lumbosacral 
herniations and were misleading in only 2$. In fourth lumbar hernia- 
tions apparent sensory changes helped in the diagnosis in 23$ of cases 
and led to error in l£$. Ninety-five per cent of lumbosacral herniations 
showed a diminution or absence of ankle jerk. Absence of ankle jerk 
occurred in one fourth of lumbar herniations. Absence of the knee jerk 
was not observed, although diminution of knee jerk was observed in one 
patient with herniation of the fourth lumbar disc. In one of two patients 
having third lumbar herniation, the knee jerk was diminished and the 
ankle jerk was absent. Detailed motor testing emphasized in a prior pub- 
lication by Bradford is of great importance in the diagnosis of disc 
lesion, especially those of the fourth lumbar space. In this series it 
occurred in £U$ of fourth lumbar herniations, but it also occurred in 
£7$ of negative explorations. Both of the patients in this series with 
third lumbar herniations showed dorsiflexor weakness. The author points 
out that gluteus raedius weakness, with a waddling gait is not uncommon 
in involvement of both the fourth and fifth lumbar nerves. 
An excellent article by Spurling and Grantham (33) dealing with all 
aspects of the problem of ruptured discs appeared in 19U8. The authors 
state that a thorough knowledge of the anatomic relations in the lower 
lumbar portion of the spine and of the physiology of the intervertebral 
disc is essential for a clear understanding of the clinical features of 
this disorder. The pathological changes which occur in a ruptured lumbar 
intervertebral disc are irreversible; no surgical effort can hope to re- 
store its anatomic integrity. A detailed discussion with appropriate 
illustrations are included in this article. 
The authors believe the terra "ruptured intervertebral disc, with 
or without herniation of the nucleus pulposus" more nearly describes 
the anatomic and pathologic features of the disorder than any other 
term. The term "hidden disc" seems to be an unfortunate one and in 
their experience usually represents a misnomer for a negative exploration. 
Multiple ruptured discs are rare. Low back pain unaccompanied by sci- 
atic radiation is seldom, if ever, an indication for operation for a lum- 
bar intervertebral disc. Unilateral, rarely bilateral, sciatica which 
is refractory to conservative treatment is the only significant indica- 
tion for lumbar disc surgery. Patients in their initial episode of pain 
should have prolonged conservative treatment. A large proportion of 
them will get well without surgery. 
Most patients with ruptured intervertebral discs whose symptoms 
are severe enough to justify operation present unequivocable neurological signs. Not only are these signs invaluable and accurate in diagnosis, but 
they can be relied upon in over half of the cases for localization of the 
lesion. No matter how classical the history of a ruptured intervertebral 
disc may be, the patient should never be operated upon in a remission. This 
is one of the most common causes for negative explorations• 
Disc operations may be among the most difficult surgery to perform 
properly. The operation should accomplish removal of all nucleus pulposus, 
loose pieces of annulus fibrosus and cartilaginous plates, A myelogram is 
not required for a diagnosis; it should be made on clinical findings alone, 
A rryelogram is extremely valuable in localizing the lesion where neurologic 
signs are not clear-cut. Primary spinal fusion together with simple removal 
of a ruptured intervertebral disc is not a desirable procedure. These patients 
who continue to have incapacitating backache after simple disc surgery may 
require a secondary spinal fusion, A disc operation properly performed does 
not in any way interfere with subsequent fusion operation. 
The follow-up results of 301 verified ruptured intervertebral discs 
treated surgically are presented. This survey was conducted by question- 
naires and responses. Eighty and four-tenths (80.U) per cent stated they 
were able to do the same work at which they were occupied prior to operation. 
Fourteen and nine-tenths (1U.9) per cent stated they were able to do their 
usual work part of the time but were handicapped by recurrent symptoms at 
other times. Four and seven tenths (U.7) per cent had to change their occu- 
pations because of persistent symptoms. Eighty and eight-tenths (80,8) per 
cent considered their operation to have been successful. Nine and six-tenths 
(9.6) per cent considered their operation partially successful and 9.6$ 
considered it unsuccessful. Forty-seven and two-tenths (U7.2) per cent sta- 
ted they have no leg pain whatsoever, while U6.2$ continue to have an occa- 
sional mild pain in the leg but not severe enough to be incapacitating. Six 
and six-tenths (6,6) per cent stated that they have aggravating leg pain 
constantly, in fact, .just as bad as before they were operated uppn. Thirty- 
eight and nine-tenths (38.9) claimed complete and lasting relief of symptoms 
of low back pain and fifty-four and two-tenths (5U.2) per cent stated that 
they have occasional recurrence of low back disability. Only 6,9$ claim to 
be completely incapacitated for their normal activity by persistent low back 
disability. 
Crisp (3U) presents an interesting discussion of treatment of lumbar 
disc lesion by immobilization in a plaster jacket. Lumbar intervertebral 
disc lesions are the usual cause of sciatica and a very frequent cause of 
acute and chronic backache. The patient with the tightly lordosed lumbar 
spine represents a partial rupture of the annulus with a slight bulge in the 
posterior wall, but with no actual protrusion. A kyphosed lumbar spine indi- 
cates a complete rupture of the annulus with an actual protrusion of the 
nucleus, but with the posterior longitudinal ligament remaining intact. 
Muscle spasm of the paraspinal muscles is an attempt on the part of 
nature to immobilize the lumbar spine. It is, therefore, rational to assist 
nature by immobilizing the lumbar spine in a plaster jacket. This method of 
treatment provides more complete rest and more completely immobilizes the 
damaged disc than does treatment by rest in bed alone. The plaster should 
be applied with the patient standing in a position of greatest comfort. It extends in front from the xiphoid process to the pubis, behind from the 
lower angles of the scapulae to the coccyx, and is cut away at the groin 
so that the patient can sit down. The plaster is changed at 3u-day inter- 
vals, but is continued from six to eight weeks and thereafter the patient 
is supplied with a lumbar brace which is worn for a further period of three 
to six months. In cases of rupture of the intervertebral disc with sciatica, 
immobilization should continue in plaster from ten to twelve weeks. The aim 
of the treatment is to produce a fibrous ankylosis around the injured disc. 
In every case of a major disc lesion it is advisable for the patient to sub- 
sequently follow a sedentary occupation. 
Between U00 and 500 cases of ruptured intervertebral disc have now been 
treated by immobilization in a plaster jacket and in approximately 90$ of 
the cases, complete and permanent relief has been obtained. In the remainder, 
although the majority have experienced considerable relief, in a small num- 
ber of cases operative intervention has been necessary. Surgery is reserved 
for those patients who cannot be made comfortable in a plaster jacket after 
two attempts. 
In an article on "Low Backache, Sciatic Pain and Herniated Nucleus 
Pulposus" Rowbotham and Whalley (35) review the records of 200 operative 
cases of patients suffering from herniated nucleus pulposus in whom laminec- 
tomy was performed. All of the patients operated had been completely incap- 
acitated as the result of low backache and sciatica for all kinds of work 
for at least four months, patients with sciatica due to causes other than 
herniated nucleus pulposus were excluded from this series. 
Signs and Symptoms* The percentage of patients sufiering from the clas- 
sical symptoms of herniated nucleus pulposus are included in this article. 
Thirty-eight per cent gave a history of injury and 6U$ gave no history of 
injury. One-third of the cases began with gradual onset of sciatic pain, 
while 26.5$ had a gradual onset of backache as the presenting symptom. Twen- 
ty per cent had sudden onset of backache as the initial symptom, while 13*5$ 
had experienced sudden onset of sciatic pain. Eighteen per cent of the pa- 
tients had intervals of complete freedom from pain, while in 82$ the symptoms 
had been continuous but of varying severity. Physical signs included 68.5$ 
with severe limp, 75.5$ with decreased lumbar lordosis, 6U$ with scoliosis, 
Ul,5$ had local tenderness over the sciatic nerve, 86$ haa limitation of 
straight leg raising, muscular atrophy was present in h0,5$ and objective 
sensory changes were present in 29$. Restriction of spinal movement was most 
marked on attempted forward flexion with only 27$ having restriction of spinal 
extension. 
Accessory Methods of Diagnosis* Only one case of partial block of 
cerebrospinal fluid was demonstrated out of 67 lumbar punctures and Queck- 
enstedt»s tests. Spinal protein was elevated in approximately 50$ of cases. 
Air myelography-proved of little value and only seven cases had lipiodol 
myelograms done for the purpose of excluding tumors of cauda equina. 
Operative Methods and Findings? Bilateral laminectomy was performed in 
37$ of the cases and hemilaminectomy in 63$. In the beginning of this series 
bilateral laminectomy was the usual procedure but as time progressed, hemi- 
laminectomy was found to give adequate exposure in most instances. The choice 
of exposure must be decided at time of operation and depends upon anatomical 
and technical conditions. Too heavy retraction of a muscle group will damage its nerve supply and lead to muscle weakness and postoperative complaints of 
pain and weakness in the back. The principle of the operation is not that 
of laminectomy but of adequate exposure of a given nerve root from the theca 
to the intervertebral foramen. 
Types of Herniation of the Nucleus Pulposus; 1, Local protuberances 
due to loose fragments is the most typical type of herniated nucleus pulpo- 
sus, 2. Local protuberances not due to loose fragments is characterized by 
an obvious conical mound at time of exposure, 3* The degenerated disc in 
which the protuberance is less conical, the base is broader and the swelling 
less localized. In these cases rupture of the annulus fibrosus has been ex- 
tensive. U. The fibrotic nodule is characterized at surgery by fibrotic no- 
dules lying beneath the affected nerve root to which it is bound tightly by 
strong adhesions, requiring sharp dissection to free the nerve root, 5. Spon- 
taneous rupture of a herniation is characterized at operation by dense gray 
adhesions around the nerve roots which are bound tightly to them by fibrous 
tissue and require sharp dissection for removal. 6, The intermittent pro- 
trusion of a herniated nucleus pulposus is a sessile type of protrusion and 
appears only on certain degrees of spinal flexion. 
Long-Term Results: The patients included in this series were followed 
from three months to three years after operation. The survey showed that 
96% of the patients were occupied in some form of employment and that only 
U% were doing no kind of work whatsoever. The patients who returned to work 
did so, on the average, four months after operation. The results were poorer 
in Armed Service personnel than in civilians. 
Residual Symptoms: Listed below in table form are the residual symptoms 
of the patients in this series? 
Site of residual pain 
(if any) 
Laminec- 
tony 
(disc 
found) 
Hemi- 
laminec- 
tomy 
(disc 
found) 
Laminec- 
tomy 
(no disc 
found) 
Hemi- 
laminec- 
tomy 
(no disc 
found) 
Total 
Back 
11 
6 
1 
2 
(13.3$) 
20 
Back and leg 
9 
17 
u 
h 
(22.72) 
3h 
Leg 
3 
7 
0 
0 
( 6.7%) 
10 
No pain in back or leg 
23 
59 
2 
2 
(57.3$) 
86 
A detailed discussion of the results shown in the above table is included 
in the article. 
Patients with no Herniated Nucleus Pulposus? A herniated nucleus pulpo- 
sus was not found on 22 occasions out of the series of 200 laminectomies. In 
the present long-term review of 150 laminectomies there were fifteen negative 
explorations. Included in these fifteen negative explorations was one case 
of tuberculoma and nine patients with extradural root adhesions and five in which no pathology at all was found. The case of tuberculoma was completely 
relieved of excruciating sciatic pain and five of the nine patients with 
extradural root adhesions had a satisfactory result. Four out of the five 
cases in which no pathology was found had a satisfactory result. 
Potter (36) discusses the problem of"Protruded Disc Sciatica in the 
Services and its Management" under the following headings; 1, Assessment 
of the Pain: In order to accurately appraise the patient’s pain, early 
transfer of these cases to a special center is recommended. Here the same 
medical officers will have the advantage of getting to know the patients 
during the period of conservative treatment, that, in all probability, will 
operate on patients if surgery be indicated, 2, Conservative Treatment: 
Bed rest for one month in all cases is utilized. In the absence of a defi- 
nite history of pain being worse at night, patients suffering only mild 
amount of pain will object to this form of treatment. Aspirin and codeine 
and morphine, in rare instances are utilized for relief of pain. Diarrheas 
should be controlled promptly and irritating purges avoided because these 
enhance the discomfort of the patient. Scoliosis and hip flexion deformities 
are corrected as soon as the acute pain phase is passed by utilization of 
exercises, but manipulation later under anesthesia may be necessary. Cases 
with severe deformities are usually candidates for operation. After a month 
in bed, a week of graduated exercises follow, and the milder cases who are 
relieved of pain are returned to duty. Those who are unrelieved are out to 
bed for an additional month’s rest. If essentially no improvement is shown 
after two month's rest and the case is not suitable for surgery, the patient 
should be separated from the Armed Forces, If the pain and physical signs 
become progressively worse with bed rest, neoplasm should be suspected, 3, 
Operation; No serviceman should be operated on for protrusion of the inter- 
vertebral disc unless it is absolutely necessary, because of the proportion 
of cases that return to duty is not satisfactory, U. Indication for Opera- 
tion: a. Indisputably severe or disabling pain prolonged for, or recurring 
over a period of at least two months, during which time strict bed rest has 
been observed, b. Severe neurological signs, such as marked involvement of 
the cauda equina, or great weakness in one or both limbs, notably such as to 
cause foot-drop, c. Severe tension signs; These include severe limitation 
of straight leg raising combined with marked limitation of spinal movement, 
in association with marked scoliosis or hip flexion deformity. 
A statistical analysis of the history, symptoms, findings, laboratory 
examinations, operations and results of a series of dislocated discs in the 
lumbar region is reviewed by Lyerly and Grizzard (37) • The most frequent 
site for a dislocated disc has been the fourth or fifth lumbar interspace 
in 96 to 98 per cent of cases, according to various writers. The discs in- 
volved in this series have been in the third, fourth and fifth lumbar inter- 
spaces with the majority at the latter two. 
Table 1. Dislocated Lumbar Discs 
Discs 
122 
Patients 
121 
Duplications 
1 
Male 
83 
68$ 
Female 
39 
32$ 
250 The incidence of dislocated discs of the lumbar spine is reflected 
in the following table in this series: 
Table 2. Age Groups 
Years 
Number 
Percentage 
7T30 
23 
IBT9 
n-uo 
U5 
36.9 
Ui-50 
37 
30.3 
51-60 
12 
9.8 
61-70 
5 
U.l 
Table 3 below gives a statistical analysis of the symptoms of patients 
in this seriesi 
Table 3. Symptoms 
Number 
Percentage 
Injury 
—w 
—m— 
Back Pain 
HU 
93 
Leg Pain 
122 
100 
Sensory Change 
80 
65 
Pain on? 
Coughing 
93 
76 
Sneezing 
8U 
69 
Straining 
69 
55 
No pain on: 
Coughing, Sneezing 
or Straining 
19 
15 
Low back pain is the first symptom of a dislocated disc and precedes 
the sciatica or leg pain some days, weeks or months. Only 7% of the cases 
gave no history of back pain. Leg pain or sciatica was present in 100$ of 
the cases. The history of pain on coughing, sneezing and straining is im- 
portant since these acts raise the spinal fluid pressure and distend the 
dural sac. If there is a complete or partial blockage, the pain will be 
aggravated along the course of the nerve root. 
Table h: Findings 
Number 
Percentage 
Hyp algesia 
—W 
tiO 
Normal Sensation 
2h 
20 
Muscle Atrophy 
22 
19 
Kemig 
109 
90 
Lasegue 
107 
89 
Naffziger 
82 
• • 
Positive 
68 
83 
Negative 
Hi 
17 
Not Stated 
Uo Table 5. Spine 
Spinal Tenderness 
Number 
Percentage 
“79“ 
No Tenderness 
11 
9 
Not Stated 
15 
12 
Lordosis 
25 
20 
Scoliosis 
U2 
3U 
Nerve Tenderness 
50 
Ul 
In observation of the patient’s spine the first thing noticed was 
scoliosis with listing to one side. Sometimes the listing was toward the 
affected side but sometimes to the other. The hip on the affected side was 
held higher so that there was convexity of the lumbar curve to the opposite 
side. In addition, there may be seen a flattening of the lumbar lordosis 
and in some cases a tendency to a kyphosis. 
Abnormal tendon jerks were listed as diminished or absent. The knee 
jerks were abnormal in 16$ of the cases, while the ankle jerks were abnormal 
in 60$ of the cases. The reflexes were recorded as normal in 39$• 
X-rays of this series were normal in U6$ of the cases and ho definite 
reliance could be placed as to the location of the disc or the presence of 
a disc in regard to the x-ray findings. 
In this series of patients 22 had pantopaque injections or spinograms 
to aid in the diagnosis, but in the majority of cases with a typical history 
and neurological findings, the diagnosis can be made more readily and accur- 
ately without the aid of a pantopaque study. Atypical cases should have 
pantopaque studies made. In this series a positive nyelogram for a disc was 
correct in 72$ and incorrect in 1U$. A false negative myelogram stucfy- was 
found in three cases or 1U$. The pantopaque study should always be made when 
there is a possible tumor of the spinal cord or cauda equina. 
Only twelve cases in this series had spinal fluid analysis with 58$ 
of these showing increase in spinal protein and only U2$ showing normal pro- 
tein content. 
Preoperative diagnosis of the disc involved was correct in 83$ of cases 
and incorrect in 17$. Since the operative exposure included two or more 
discs at every operation, the slight error in the preoperative diagnosis made 
little difference, A single disc involvement was found in ?2$ of the cases. 
Two discs were involved in 23$ and three disc lesions were found in 2.5$ of 
the cases. The operative findings for disc involvement were negative in three 
cases or 2,5$ of the series. In the negative cases the removal of ligamentum 
flavum and decompression of the nerve root may relieve tne symptoms. The 
results have been good in the author’s experience. 
Only one patient was reoperated on for recurrence of a dislocated disc. 
A tumor of the cauda equina was found in two cases, including an intradural 
meningioma and a malignant hemangio-endothelioma which metastasized to other 
places in the spine and the brain, and the patient died in the hospital which 
was the only death in this series. Table 13 below gives the results of the study in this series: 
Table 13, Results (72 Cards, or 
59 per cent. Returned) 
Number 
Percentage 
Slightly Improved 
12 
17 
Greatly Improved 
h9 
68 
Cured 
11 
15 
Working 
63 
88 
Back Pains 
5U 
75 
Leg Pains 
h6 
6U 
A large percentage of patients with disc lesions have back or leg 
pains at some time more than a year after operation although these symptoms 
may not preclude the.patient from returning to work. Strenuous physical 
work is more apt to cause low back pain following disc removal. 
There were 35 patients classified as compensation or insurance cases 
in this series and of these eleven replied to the statistical survey con- 
ducted, Table 15 below shows the results of insurance cases operated on; 
Table 15* Insurance Cases (11 of 35 Cards 
Re turned) 
Slightly Improved 
Number 
—u 
Percentage 
J6 
Greatly Improved 
6 
Sh 
Cured 
2 
18 
forking 
Q 
y 
81 
Back Pain 
10 
90 
Leg Pain 
9 
81 
There was not a great deal of difference in the frequency of back and 
rleg pains in the two groups after operation. 
A detailed and exhaustive review of 100 consecutive cases operated on 
for intervertebral disc protrusion is reported by Falconer et al, (38) 
which includes a group of 77 cases where severe and intractable sciatica 
predominated, in conjunction with a group of 23 cases where severe and per- 
sistent low back pain predominated. The patients were selected from all 
grades of society from a much larger group of 300 to 350 patients referred 
for examination. The predominant neurosurgical signs were exacerbation and 
pain on coughing or sneezing, some degree of limitation of straight leg 
raising in nearly all cases of sciatica in association with a slight degree 
of weakness of the ankle movement. Rigidity of the lumbar spine was present 
in all cases of low back pain and in most cases of sciatica. Absence or 
diminution of the ankle jerk v/as often present with protrusion at the lumbo- 
sacral space, while sensory disturbances conforming to either the fifth lum- 
bar or first sacral dermatome patterns were present in a large proportion 
of cases. 
Each case of sciatica had disc prolapses at time of surgery either at 
one or both of the lower two lumbar intervertebral discs. All of these cases 
were improved on their preoperative status, although for various reasons nine 
cases reouired more than one operation. Forty-one percent of all cases were completely relieved of leg and low back pain while the remaining cases had 
persistent symptoms, although appreciably lessened. All but two of the 
patients with low back pain had intervertebral disc lesions at operation. 
Benefit was obtained in all but two cases and only five cases of this group 
required further operation. 
Selection of cases for operation was restricted to those who were unable 
to undertake light, continuous work and who had undergone a period of four 
to five weeks of complete rest without adequate relief after tuberculosis, 
neoplasm or other disease of the spine were excluded. A myelogram helps to 
localize the disc and foretell its nature, but is not absolutely diagnostic 
in all cases. In selection of cases for operation with low back pain without 
sciatica, more caution was observed. No patient with this complaint was 
operated on without positive myelographic evidence of disc protrusion. Ade- 
quate exposure of the affected disc is a mandatory surgical requirement. 
Removal of the ventral spine and lamina is performed in each instance where 
required and no increased disability has been noted in these patients. Rec- 
ognition of pathological disc at operation is explained and divided into 
four types, namely, projections, extrusions, intermittent prolapses, and 
scarred discs. A description of these classifications is given. The defini- 
tions correspond to commonly accepted standards except that the term inter- 
mittent prolapse is used instead of concealed ruptured disc as described by 
Dandy. This type of disc can be made to protrude at operation ty breaking 
the table so as to hyperextend the patient*s hips and spine. This type of inter- 
vertebral disc protrusion occurred in 33 of the patients for a percentage of 
27$ of all discs removed at operation. Excessive mobility of the lumbar 
spine as indicated by forceful motion at time of operation helps in locating 
the diseased intervertebral space. Thorough curettage of the affected disc 
is the most important single precaution to be observed during an interverte- 
bral disc operation. This should be accomplished even if removal is required 
to be carried out from both sides of the theca. Thickening of the ligamentum 
flavum and marked prominence of the extrathecal veins have been regarded as 
normal anatomical variations, but pronounced swelling of nerve root has been 
considered as a secondary factor of nerve-root compression and not as evidence 
of primary neuritis. In seven of the cases reported leptomeningeal adhesions 
causing matting of the roots of the cauda equina have been observed, but in 
each instance this condition was associated with a disc prolapse, followed by 
relief of symptoms in six patients. In none of the cases reported was a 
decompression of a spinal nerve root done at the level of the intervertebral 
foramen. Spinal fusions are not considered as improving the end result. 
Fourteen patients in this series required a second or even a third oper- 
ation because of persistent or recurrent symptoms and were classified as 
follows? a. Cases in which the disc lesion responsible for symptoms had not 
been recognized at the original operation—-3 examples, b. Cases in which 
the responsible disc lesion had been dealt with inadequately at the original 
operation—8 examples, c. Cases in which subsequent symptoms were due to 
a second disc protrusion occurring at another level—2 examples, d. Cases 
in which spondylolisthesis developed producing symptoms—1 example. 
At the second or third operation, in order to prevent opening the theca 
inadvertently, it is the author's practice to expose the lateral bony wall of 
the spinal canal and by dissecting the scarred theca from it to approach the 
posterior aspects of the vertebral bodies and so the intervertebral discs. The recognition of other lesions which may simulate disc protrusions is 
essential to good disc surgery, and include tumors of the cauda equina, gran- 
ulomatous disease of the intervertebral disc, tumors, diseases affecting the 
spine, and spondylolisthesis. Anomalies and acquired abnormalities of the 
spine demonstrable by x-ray examination are considered only as incidental 
findings or else secondary manifestations of the patient's complaint. 
Intervertebral disc operations are liable to the same complications as 
other major surgical procedures, including wound infections, femoral vein 
thrombosis, pulmonary infections, etc. There are, however, some complications 
which are peculiar to this operative procedure and include extrathecal leak- 
age of cerebrospinal fluid, spondylolisthesis, causalgia, acute postoperative 
aseptic leptomeningitis, injury to the aorta and inferior vena cava and para- 
lysis of the cauda equina* The authors have not experienced all of these 
complications, but a discussion of these complications is presented. 
Lindblom (39) describes a method of diagnostic puncture of interverte- 
bral disc in sciatica. The indication for a diagnostic disc puncture is 
long-standing sciatica which has not responded to conservative treatment and 
which has a negative myelogram without definite localization of the disc 
protrusion. Under x-ray control, usj.ng a double needle, the inner one with 
a diameter of 0,5 mm. is introduced into the center of the disc and an opaque 
medium is injected. If the punctured disc is the cause of the symptoms of 
lumbago and sciatica, the pains caused by the injection will remind the pat- 
ient of his usual complaints. Following injection appropriate x-rays are 
made which demonstrate the presence of a disc as it punctures through the 
posterior portion of the annulus fibrosis. Excellent pictures demonstrating 
the presence of a protrusion of an intervertebral disc are included in this 
article * 
The diagnostic disc punctures have not been followed by any late complaints 
of the patient or other complications. At the insertion of the needle through 
the dural sac two patients experienced shooting pains from root puncture, but 
after a slight change of direction the needle bypassed the roots without caus- 
ing pain. Too few cases have been done to fully appraise this method of 
diagnosis, but it seems to give great clinical promise. 
Caldwell and Sheppard (U0) examined and analyzed 75 cases who had under- 
gone removal of a ruptured disc, three to seven years previously. Eighty- 
two and sixty-seven hundreds(82.67) per cent showed good results and 17.33$ 
showed unsatisfactory results. Six cases were recurrent with good results, 
but for this reason were excluded. If these cases are included in the total 
of good results, it brings the percentage to 90,67 which compares favorably 
with the results obtained by Ghormley and associates; Smith, Deery and Hagman; 
and Barr in which the combined operation of spinal fusion and disc removal 
was performed. Reference is made to similar results obtained by Friberg five 
years after simple removal of the disc, in an examination of hi patients. His 
series showed 83.8$ of the patients to be relieved from sciatic pain and 70% 
to be relieved of back pain as well. If so many good results can be secured 
by laminectomy alone, the necessity of the combined operation of disc removal 
and spinal fusion may be doubted. 
The incidence of recurrence from three to seven years after the first 
operation is 8%, but without exception, these patients were relieved of pain in the back and lower limb for varying periods of time before and after the 
second operation. It is admitted that stabilization of the affected seg- 
ments of the spine may reduce the percentage of recurrences, but it is 
remembered that the statistics of Bosworth and others on fusion of the spine 
show the failure of fusion occurs in IS to 2S% of the cases, Successful 
spinal fusion, according to Love does not in each instance prevent the re- 
currence of additional herniated discs. Statistical analysis of congenital 
anomalies does not indicate a higher percentage of unsatisfactory results in 
these patients. The hypertrophic changes with narrowing of the interverte- 
bral disc or a combination of both conditions which occurs postoperatively 
following simple removal of the disc could not be shown to have any bearing 
on the good results obtained in these cases. 
The incidence of good results can probably be increased when proper 
attention is paid postoperatively to the following factors: 1, Weight con- 
trol; 2, A regulated increase in activity, compatible with the patient's 
age and general condition; 3. Special exercises to strengthen and increase 
the suppleness of the involved muscles, lu An explanation to the patient 
of the cause of the residual pain; 5., Reassurance, This is perhaps the 
most important and may obviate the necessity for other measures. In conclu- 
sion, no criteria for spinal fusion following removal of a herniated nucleus 
pulposus are known. 
Reviewing the history and physical findings of ruptured intervertebral 
discs Bakhsh (Ul) states that his object in writing this article is to create 
interest in this subject by the profession in order to increase the accuracy 
of diagnosis and institute proper treatment, which in his opinion is surgi- 
cal excision of the intervertebral disc. The history most commonly found is 
low back pain for a variable period of time, followed by sciatic pain, accen- 
tuated by coughing, sneezing, forward bending or lateral flexion, with ting- 
ling or numbness in certain parts of the lower extremities. Physical exam- 
ination reveals obliteration or alteration of the lumbar curve, scoliosis, 
elevation of the pelvis on the affected side, inclination of the body towards 
the sound side, positive straight leg raising test, positive jugular com- 
pression test, and the usual deep tendon reflex changes, in association 'with 
the usual altered sensory examination. Other conditions which are confused 
with ruptured intervertebral disc are granulomatous conditions of the spine, 
as syphilis, tuberculosis and other spinal affections, sacroiliac troubles 
and pelvic disease, especially in females. 
Several microphotographs, diagrams, statistical tables and pictures are 
reproduced by Lindblom and Rexed (U2) to show that macroscopically visible 
compression and deformities of spinal nerve roots and ganglions by dorso- 
lateral disc protrusion are regularly associated with typical and often exten- 
sive nerve injury as clearly seen in microscopical sections of the nerves and 
ganglia. Diffuse degeneration mixed with regenerative processes of varying 
intensity were found especially in ventral root fibers. The spinal ganglion 
cells were often definitely deformed and atrophied by pressure and the spinal 
ganglion as a whole showed an increased amount of connective tissue and gross 
alteration in its internal structure. The severity of the nerve injury was 
on the whole proportional to the degree of the macroscopical compression. 
Occasionally osteo-arthritic enlargement of the intervertebral joints was 
found to be an accessory factor in causing nerve damage. The mechanism of 
compression and spatial relationship between nerves and the surrounding struc- 
tures in the intervertebral canal are described fully. The relationship between the nerve injury by the disc protrusion and certain arachnoidal proliferations 
around the spinal roots is briefly mentioned. 
Holscher (U3) reports a case of vascular damage to the greater vessels 
lying anterior to the fourth lumbar vertebra during surgical removal of the 
intervertebral disc between L-U and LS by the use of the pituitary rongeur 
in the hands of a competent surgeon* The postoperative course of the patient 
is described in detail* Six months after disc surgery corrective vascular 
surgery was carried out transperitoneally through a lower right rectus inci- 
sion. An anuerysmal sac measuring approximately three centimeters in diameter 
was found at the right common iliac vessels. The sac was obliterated by 
ligation of the artery and vein above and below it, after which the patient 
made a steady and progressive recovery. 
Four other known but unpublished instances of similar vascular damage, 
each with grave results, are known to have occurred. The fatal outcome in 
the majority of these cases places this complication among the dire surgical 
emergencies. Upon the slightest suspicion of vascular damage large amounts 
of whole blood should be made available at the earliest possible moment. In 
any instance where the patient’s circulatory condition shows marked change, 
there seems real indication to attempt immediate repair of the vascular in- 
jury, Because of the possibility of vascular injury it is advisable to rou- 
tinely determine preoperatively the blood type and the Rh factor of the 
patient. 
Shaw (UU) discusses the possibility of ruptured intervertebral,disc from 
positive acceleration in flight. The flexed spine may be injured by positive 
acceleration of magnitude which is readily withstood by the erect spine. For 
this reason it is advisable to maintain an erect spine during exposure to 
positive acceleration whether in curvilinear flight or in the ejection seat 
of an aircraft. A case of proven and a case of probable herniated nucleus 
pulposus resulting from a dive and ’’pull-out” are reported. 
Pott (U5) presents a synopsis of a paper entitled ’’Lesions of the Inter- 
vert ebraT Disc” under the Section of Orthopaedics of the 116th Annual Meeting 
of the British Medical Association. Protrusion of intervertebral disc sub- 
stances occurred in approximately 300 new cases per million population per 
annum although insurance statistics tended to show that this was a conserva- 
tive estimate. Trauma was an etiological factor in approximately $0% of the 
cases. Males were involved twice as often as females. In half of the cases 
radiological narrowing of the disc was found, and in a similar proportion 
there was a significant rise in the protein content of the cerebrospinal 
fluid. Bilateral syndromes might be produced by single disc protrusion or 
by a double lesion of the same disc or by single lesions of two discs. Skel- 
etal peculiarities of congenital origin sometimes caused difficulty in local- 
ization of the ruptured disc, but otherwise were not of significance in rela- 
tion to treatment. 
At operation precise hemostasis was necessary with complete removal of 
all nuclear tissue effected by special gouges and nibblers copied respective- 
ly from those used by the dental surgeon and the otolaryngologist. In disc 
syndromes associated with spondylolisthesis the loose neural arch was removed, 
the prominent edge of the lower vertebra smoothed off, and after the disc had 
been removed, bone chips were put in its place and tibial grafts inserted posteriorly* The author*s experience in diagnosis was correct in 93$ of 
cases and errors were generally due to the presence of multiple protrusions. 
Second operations were necessary in only 2$ of the cases. Operative results 
showed no mortality, and 85$ of the patients were fit for their former or 
equivalent jobs. Fusion operations were not necessary. Forcible manipula- 
tion was dangerous and epidural injection did not help. 
In a discussion of the development of ruptured intervertebral disc, 
Raney and Raney (U6) have the following to say. In selection of patients 
for operation the authors required: 1, Acutely disabling and intractable 
pain and physical signs of disc lesions not responding to physical treatment. 
2, Recurring attacks of acute disabling pain and physical signs where it is 
economically unsound to continue conservative management, 3* Danger of 
irreversible neurologic changes (only occasionally encountered). Surgical 
treatment is designed to terminate the operation of pathogenic internal 
forces by removal of all abnormal material from the affected disc accompanied 
by intervertebral replacement of the disc with bone chips. The purpose of 
bone chips is not to produce a bony union but to maintain the joint space 
and provide a framework for cicatricial formation. In the majority of cases, 
the calcium had disappeared by the end of six or eight months without fusion. 
Since the fourth and fifth lumbar discs are so frequently affected, explora- 
tion of both of these is recommended at t ime of surgery with inspection of 
the third in case of doubt. 
Part of the statistical analysis showed 168 of the cases to be private 
and 32 to be industrial cases. Of the private patients 85*1$ returned to 
their original work, relieved; while 8.9$ were relieved but changed to light- 
er occupations, making a total of 9k% good results. Three and five-tenths 
(3.5) percent were relieved of their preoperative physical evidence of dis- 
ease but continued to complain and were, therefore, classified as unimproved. 
Two and five-tenths (2,5) percent were unimproved, showing varying degrees 
of muscle spasm on activity and were suspected of having additional disc 
disease. Results of the industrial cases of which there were 32, were not 
so encouraging. Forty three and seven tenths (U3.7) percent returned to 
their original work; 3.2$ were unimproved; 3k M were relieved of objective 
signs but did spotty work, remaining back conscious and compensation minded; 
18,7$ were relieved of objective signs but complained of pain when instructed 
to return to work. Part of the undesirable results in this group was attri- 
buted to poor handling of compensation by the insurance carrier. 
If surgery is limited to positive findings by myelography, much of the 
disease will be missed* Leg pain will ordinarily be relieved but disabling 
backache returns from involvement of adjacent lesion or lesions in a sizable 
percentage of the cases. Spondylolisthesis, spina bifida, anomalies, facets, 
etc., were among the cases operated and the response to removal of the dis- 
eased disc or discs did not differ from the response in those cases with 
architecturally normal spines, however these defects may predispose to rup- 
tured discs. 
Approximately 80$ of the patients suffering from diseases of the discs 
can be recognized by physical findings and clinical history, rendering spinal 
myelogram unnecessary and undesirable. Only those patients showing a varia- 
tion from the typical picture of disc disease should be subjected to spinal 
myelography. Wilson (U7) reviews the present concept of diagnosis and treatment of 
protruded lumbar intervertebral discs with primary emphasis being placed on 
the necessity for a myelogram as a diagnostic procedure to be performed in 
each case of suspected intervertebral disc, Myelographic examination will 
show the correct level in 90% of positive protruded discs which are clini- 
cally apparent, Pantopaque is the material of choice and the types of roent- 
genological defects are classified as follows: 1. Lateral pressure defects. 
2, Nerve root defects, 3. Hour glass defects (due to bilateral protrusion). 
U. Gap defects (due to midline protrusion), 5. Block defects (complete 
midline occlusion), 6, Veil defects (incomplete midline protrusion in which 
the oil column is thinned as it passes over the defect). 
The causes of false negative rayel©graphic studies are attributed to: 
1, Epidural injection of wall, 2. Large epidural varicosities, 3* Hyper- 
trophic spurs of vertebrae, U, Needle defect due to tension on the dura. 
Protrusions most likely to be missed are those of the fourth and fifth 
lumbar vertebrae where the dural sac is narrow and the protruded disc pro- 
duces no pressure on the oil column or on the nerve sheath, A negative mye- 
logram is of value in those patients with apparent clinical ruptured disc 
because the disc will most often be found in these cases at the lumbosacral 
level. No series of cases is preserfted for statistical analysis and opinion 
is based primarily on author's clinical expetience. 
Black (hd) discusses eleven cases of the massive herniation found in the 
literature and reviews three illustrated case reports. Analysis of the case 
histories reveals valuable information in arriving at a diagnosis preopera- 
tively. Briefly stated, the composite picture is chronic backache for a 
variable period of time followed by radiation of pain into one lower limb 
and succeeded by relatively sudden onset of symptoms of compression of the 
cauda equina. The differential diagnostic point between this condition and 
collapse of a vertebra following invasion by tumor or collapse ‘of vertebra 
weakened by infection can be made by suitable x-rays or by the characteristic 
slow onset of paralysis in these lesions. In contrast, the paralysis is 
relatively rapid when due to herniated disc. 
Satisfactory recovery in the cases studied was in direct proportion to 
the rapidity of surgical removal following the sudden onset of a symptom 
complex of the cauda equina. An instance is cited in which there was a pro- 
longed period between compression of the cauda equina and operation, leading 
to practically no improvement from surgery. 
Briggs (U9) states that sacroiliac subluxation does not exist as an eti- 
ologic factor causing low back disability, but only as a diagnosis causing 
confusion. Confusion is attributed to referred pain over the sacroiliac 
joint and its ligaments accompanied by a changed relationship between the 
sacrum and the ilium due to muscle spasm. Pain and tenderness are attribut- 
able to an actual stretching of the sacroiliac ligaments while a muscle spasm 
is due to the presence of an intervertebral disc. Operative procedures should 
always be directed toward the discs and never to the apophyseal joints. These 
patients are cured with lumbosacral fusion. Myositis and myofascitis, in 
association with indurated nodules in muscle masses are occasionally the cause 
of low backache. Disorders of the intervertebral discs cause most of the pathological 
conditions for which operations are performed today, A description of the 
various locations of discs is offered with suggestions to prevent failure 
in the discovery of a ruptured disc. Foraminotomy with exploration of the 
root is a necessary procedure where indicated. The reader is reminded a 
herniated disc may be protruding preoperatively and not at operation due to 
a return of the ruptured disc to its parent site and to the positioning of 
the patient on the operating table which causes the disc to be sucked flat. 
The-sense of feel helps tell the surgeon when the disc is pathologically 
soft, but the author recommends exposure of the disc to permit palpation and 
direct observation. Despite the author’s surgical search for herniated disc 
and nerve root compression, operations with negative pathological findings 
are not infrequent, Pantopaque or any other contrasting material will not 
solve the problem. It will always rest, particularly in the fifth lumbar 
foraminal situation, in the judgement and skill of the orthopedic surgeon. 
Herz (50) reports three cases of sciatica caused by cyst formation in 
an old hematoma in association with fascial fat herniations. Surgical re- 
moval of the herniated fat, plus the cyst formations in old hematomata, pro- 
duced relief of backache and generalized sciatica. The cysts were removed 
from the buttocks. Pictures of pathological sections and a diagram showing 
the site of cystic lesions causing symptoms are included in the article. 
A group of 95 postoperative disc patients were studied by Grant et al 
(51) in the Neurological, Orthopedic and Roentgenological Departments of the 
University of Pennsylvania, Sixty percent of the patients were regarded as 
cured and were able to pursue a normal full day’s work without any back or 
sciatic pain, while 87$ of the patients were satisfied with the results of 
the operation. The factors of age, trauma or type of occupation appeared 
to have no relationship to the type of injury and the type of operation ap- 
peared to be unrelated to the results, Air myelograms were helpful but not 
as sufficiently diagnostic as oil myelography, preferably pantopaque, and 
the recommendation was made that it be used routinely. The greater the dis- 
placement of* nucleus pulposus, the more satisfying will be the result. Lost 
or diminished Achilles reflexes do not often return and recovery from para- 
lysis is extremely uncommon. No relationship between increased narrowing 
of the intervertebral space and clinical result can be shown. Fusion of 
the vertebral bodies or dense bridging occurred in six patients, all of whom 
are in the group of clinically well. It could reasonably be postulated that 
more mil develop this change as time goes on, but further follow-up studies 
will be necessary to substantiate or disprove this point. It is unlikely 
that the presence of a significant quantity of residual opaque oil in the 
caudal sac has any influence upon the clinical result. The fundamental 
principle for good results is careful selection of patients with exclusion 
of those cases that fail to measure up to an exacting histoiy and physical 
examination supported by a positive myelogram. 
Friberg (52) reviews the anatomical relationship of the nerve root to 
the lumbar disc and presents pictures of anatomical specimens which illustrat 
this relationship. Special emphasis is placed on the relationship of the 
fifth nerve root which leaves the dural sac at the level of the fourth disc, 
but does not leave the spine until the level of the fifth disc is reached. Instability of the lumbar spine is considered to be a fairly early 
clinical sign of disc degeneration and can be suitably detected in a large 
number of cases by x-ray examination. The roentgenological instability 
demonstrated was one of anteroposterior displacement of a vertebra toward 
the adjoining one. Instability of the spine is associated with an extensive 
rupture of the annulus fibrosis. This finding has been arrived at as a 
result of detailed postmortem examinations of 100 cases. 
In performing the removal of a disc, a myelogram is considered an es- 
sential adjunct in order to determine accurately the level of disc inter- 
ruption. At surgery the minimal amount of dissection is performed in order 
to shorten the period of convalescence and a laminectomy is not done unless 
absolutely necessary. Spinal fusions have not been performed following re- 
moval of a ruptured disc except in those cases where a resection of the inter- 
vertebral joint, or a facetectomy has been performed, to remove a lateral 
prolapse. Of 800 operative cases, 60% have shown excellent results and 2k% 
have shown good results or a total of Qk% results entirely satisfactory. 
At operation the bulging part of the disc pressing on the nerve root 
is removed and loose parts from the disc cavity are also removed. Scratching 
or thermocauterization is never done. The removal of an entire disc is 
unnecessary since the weight-bearing structure of the fibrous ring is not 
the nucleus pulposus. In two and five year follow-ups of many patients oper- 
ated on there has been little roentgenological evidence, if any, of disinte- 
gration of the intervertebral space, 
Early surgical intervention in patients with sciatica is not warranted 
since a large percentage of these patients respond to conservative therapy. 
Abercrombie (53) states that the minor signs of displacement of inter- 
vertebral discs are the plantar sign, the ’’forced expiration” sign, and a- 
vertical lumbar spine. The plantar sign is due to an atrophy of the tissues 
of the sole of the foot, giving rise to an appearance of wasting, and an in- 
crease in the number and depth of the corrugations of the plantar skin. These 
changes have atrophic origin. The ’’forced expiration” sign is reproduction 
of a patient's disc pain produced when the patient closes his nostrils with 
his fingers and then made an expiratory effort. This is more reliable than 
the sudden violent strain caused by coughing and sneezing since these actions 
are thought to aggravate the pain of fibresitis or myalgic condition of the 
back or chest wall. The vertical lumbar spine sign is increased extension of 
the lumbosacral joint as determined by x-ray examination. 
Craig and Kessel (5U) wrote some interesting observations concerning 
arthrogenic sciaticaand disc prolapse. They make reference to an article 
published by Mr, E. F. West, of Adelaide, in the 13th of December, 19U7 issue 
of the Australia Medical Journal which stresses that limb pain may arise from 
lumbar joint derangement independent of disc prolapse. Lewis and Pochin have 
shown that in paralysis of a nerve due to pressure, touch sense fails early, 
motor power fails next, immediate pain later and delayed pain last. Alter- 
nating periods of numbness and cutaneous tingling are the earliest signs of 
root compression. Painful stimulation of a deep somatic structure such as an 
interspinous ligament by injection of hypertonic saline results in pain through- 
out the corresponding sclerotome with accompanying muscle spasm and is indis- 
tinguishable from that occurring spontaneously in an L-£ and S-l disc lesion. Herniation of the nucleus pulposus is primarily a joint lesion since it 
causes strain on surrounding ligamentous structures and may secondarily give 
rise to spinal or nerve root compression. This is further evidenced by the 
fact that a large proportion of patients in whom disc prolapse is subsequent- 
ly found at operation never present any acceptable evidence of nerve pressure, 
such as muscle weakness, anesthesia or loss of deep reflexes. Removal of 
the disc will reduce mechanical disturbances of the surrounding tissue and 
thereby diminish the irritation which gives rise to segmental pain, but it 
will not invariably abolish the pain, because in some cases the joint remains 
grossly deranged, to act as a constant source of painful stimulation. Spinal 
fusion is, therefore, essential, however this is a severe and time consuming 
procedure, 
To further support the argument presented, application of a short plas- 
ter cast without preliminary extension may very rapidly relieve pain, although 
anesthesia persists and may actually increase. In addition, the injection of 
1$ novocaine into the corresponding interspinous ligament in cases of pro- 
lapsed discs will produce relief of pain lasting from a few hours to three 
weeks, 
In a discussion of the syndrome of protruded intervertebral disc, Oldberg 
($5>) reviews the anatomical background, symptoms, laboratory tests and presents 
three illustrative case histories, gives treatment and prognosis of protruded 
intervertebral disc. The anatomical background and concept of symptoms is 
in accord with the general understanding of these subjects. The importance 
of x-ray examination is stressed with the statement that at least 7S% of the 
cases will have negative x-ray examinations, Lumbar puncture is not routine- 
ly recommended but is declared mandatory in those cases in which there is 
possibility of any other lesion being the cause of the patient*s pain. Mye- 
lography should be reserved for particular cases in which it seems especially 
indicated, with the reservation that, as radiologic techniques improve and 
the substances used, for myelography are also improved, this procedure may 
become more universally used and even essential. In consideration of treat- 
ment, surgery is not recommended until conservative measures have been ade- 
quately tried and until recurring symptoms with resultant disability have 
proved beyond doubt that one must proceed surgically. In conservative manage- 
ment of these patients it.is essential that weight lifting be avoided and 
that the patient sleep upon a stiffened mattress. Physiotherapy almost always 
does harm. This is certainly true of mechanical manipulation, either active 
or passive, and is even true of diathermy and similar treatments in a fair 
proportion of cases. When surgery is performed, adequate exposure is essen- 
tial and the author removes as much bone as may be necessary to obtain ade- 
quate exposure which may be a half or a third of the lamina. All loose pieces 
of disc material are removed, including those within the cavity of the disc 
itself but no other operative technique is followed. 
In reference to prognosis, the author believes that patients with a 
ruptured disc will always have a weak back. He does not consider it advisable 
to return the patient who has sustained an injury while doing heavy labor to 
this occupation. 
In a discussion of the conservative treatment of lumbar disc lesions 
Crisp (56) states that the majority of lumbar disc lesions with or without 
sciatica generally recover completely if treated by adequate conservative 
262 measures. Bed rest, in itself, is insufficient. Muscle spasm is an attempt 
on the part of nature to stabilize the lumbar spine. A plaster cast applied 
with the patient in the most comfortable position, extending from the manu- 
brium to the symphysis in front, from the inferior angles of the scapulae to 
the coccyx posteriorly, and cut out to allow the patient to sit, will furnish 
added and almost complete immobilization of the spine, thereby relieving the 
patient of his pain and allowing him to return to his former occupation quick- 
ly without prolonged hospitalization. Immobilization allows reparative pro- 
cesses to occur, including adaptive shortening of the ligaments and muscles 
at the site of the lesion and restriction of forward motion. After removal 
of the cast the patient is given hyperextension exercises, but forward flex- 
ion is allowed to return naturally. Three patients with acute sciatica fol- 
lowing rupture of an intervertebral disc were shown, wearing plaster jackets. 
English and Spriggs (57) made a study of eighteen cases whose findings 
were compatible with diagnosis of herniation of the nucleus pulposus. Seven 
cases had relief of pain following lumbar sympathetic ganglia block. It was 
not possible to rule out the possibility of infiltration of the sciatic nerve 
root with some of the procaine at the time of injection. In order to obviate 
this possibility, tetraethylammonium chloride, which has a selective action 
on sympathetic and parasympathetic systems, was utilized in a series of 
eleven cases. Eight patients had complete relief of pain; two had some res- 
idual pain; and one patient had no,relief of pain. The period of relief from 
pain was quite variable, lasting from thirty minutes to 28 days in two cases 
with still no return of pain at time of publication of the article. 
Based upon this evidence it appears that sympathetic ganglia are either 
directly involved in the transmission of pain in certain cases of herniation 
of the nucleus pulposus or that blockage of sympathetic pathways in some way 
relieves the pressure around the nerve root near the site of the disc mater- 
ial, Two explanations are offered for the relief of pain in these cases? 
(a) Afferent pain carrying fibers course through the sympathetic ganglia, 
or (b) Sympathetic fibers are involved in the production of increased nerve 
root pressure near the site of the herniation of the disc by virtue of a 
vasospastic phenomenon and increased swelling. 
Young (58) believes that disc degeneration is more often revealed by 
injury than it is caused by injury. When an intervertebral disc degenerates 
the fibrocartilage of the annulus breaks up and becomes soft, thus allowing 
an abnormal degree of movement to occur between the two vertebrae concerned. 
Such abnormal mobility has nearly always been present in the cases the author 
has referred for surgical treatment. This excessive mobility can sometimes 
be demonstrated radiographically and is the earliest effect of the disc dis- 
ease, Reparative processes are difficult and nature attempts to compensate 
for the abnormal mobility by shortening the surrounding ligaments. If liga- 
mentous shortening keeps pace with the degenerative process there will be no 
abnormal mobility and no symptoms. In contrast, if shortening lags behind 
the degeneration, the disc will be abnormally mobile and symptoms may occur. 
Later in the degenerative process osteophytes form at the margin of the ver- 
tebral bodies and produce the radiological appearance which we know as spondy- 
litis, Ankylosis is the final result of the ligamentous shortening and is 
nature's method of healing a disc lesion* The symptoms of intervertebral 
disc disease with the rational explanation of them is discussed in detail* 
263 Various means of conservative treatment are outlined. If all of these 
methods fail surgery is indicated. 
A very excellent discussion of rupture of the intervertebral disc in 
the cervical region is presented by Brain, Knight and Bull (59). The ana- 
tony, pathogenesis, symptomatology, diagnosis and treatment are covered in 
great detail. The indications for conservative and operative treatment are 
presented. 
In an article on the intervertebral disc syndrome, Lewin (60) discusses 
a historical review of the disc syndrome from as far back as 1555 with the 
works of Vesalius in describing the consistency of the annulus fibrosus and 
that of the nucleus pulposus. A statistical review of the signs and symptoms 
of various authors is included. In localization of the intervertebral discs 
reference is made to Love and Walsh who showed that 96% of all ruptured discs 
occur in the lumbar region and 96% of these are protrusions of the fourth and 
fifth lumbar discs with almost equal frequency of occurrence at each of these 
sites. The author feels it only necessary to make a diagnosis of herniated 
disc because of this fact. The diagnosis of a ruptured intervertebral disc 
at the fourth and fifth interspace is made on low midline lumbar backache, 
plus pain down the back of one or both legs, which is intensified by cough- 
ing and sneezing and must be recurring and not continuous. There may or may 
not be diminution of the Achilles tendon reflex or sensory or motor loss in 
the distribution of the fourth and fifth lumbar and first sacral nerves. 
Accessory diagnostic tests should be avoided wherever possible. The most 
reliable sign helpful in the diagnosis of protrusion of the lumbar disc are 
Lasegue's sign, sciatic nerve tenderness or diminution or absence of the 
Achilles tendon reflex on the side of pain. Consideration of differential 
diagnosis is given to a tumor of the cauda equina; congenitally defective 
fifth lumbar vertebra with destruction of the articular processes; and spon- 
dylolisthesis, all of which are relatively uncommon. The last two can be 
differentiated by roentgenograms and spinal tumors will give sensory and 
motor disturbances, in addition. Love's operative technique for removal of 
herniated disc is given. The question of combined operation of spinal fusion 
and disc removal is left to the individual surgeon. Where combined proced- 
ures are performed a neurosurgical and orthopedic surgical team is recommended. 
Kidner (61) discusses low back pain and sciatica from the standpoint of 
anatomy, diagnosis, causes and treatment. The causes include muscular strain, 
joint sprains, hypertrophic arthritis, systemic infection, fractures, congen- 
ital anomalies, anatomical abnormalities, local joint diseases, intrapelvic 
conditions, ruptured disc and acute low backache due to minor injuries. The 
author concludes that the vast majority of backaches are due to lesions ex- 
actly like those that occur in joints, bones, muscles and fascia throughout 
the rest of the body. Many cases of sciatica are due to these lesions because 
of the proximity of the lumbosacral nerve roots to the affected tissues. The 
vast majority of cases can be cured by conservative means with rest being 
emphasized as the most important requirement. Rest is obtained by recumbency 
in bed,specially designed braces, casts, and as a last resort, surgical 
fusion. Manipulation in selected cases is recommended in order to break up 
adhesions and correct faulty positions. Corrective exercise, massage and 
heat is used to restore normal posture and relieve pain. The author admits 
the entity of a ruptured disc and surgical removal is indicated in these 
patients. The diagnosis of a ruptured disc is considered difficult and its 
2 & removal does not always produce a cure. Conservatism in treatment of low 
backache with sciatica is recommended. 
Under the title of "Herniation of Fascial Fat, A Cause of Low Back 
Pain” Hucherson and Gandy (62) report 32 patients who were operated on for 
painful palpable masses in the low back. The findings agree with those of 
Herz, Copeman and Ackerman, All of the patients in this series complained 
of backache of varying degree of intensity with sciatic or radicular radia- 
tion of pain reproduced and exacerbated by palpation of painful masses in 
the low back. These trigger points occur along the lateral border of the 
sacrospinalis muscle from the costal margin to the crest of the ilium. In 
the gluteal they are found about the posterosuperior iliac spine 
and along the crest of the ilium or about 5 cm, below it. These trigger 
zones are also found in line with the sacroiliac junction but are not com- 
monly found elsewhere in the buttocks. The distribution of these areas cor- 
responds to the normal distribution of fat beneath the posterior fascia. In 
differential diagnosis of this condition no sensory changes or reflex pheno- 
mena or muscular weakness has been noted. Injection of the painful nodule 
with 1% novocaine will afford temporary relief and should always be -carried 
out as a diagnostic procedure. The infiltration of these areas may be* cura- 
tive . 
Copeman and Ackerman classified these fat hernias into three anatomic 
types: the pedunculated, non-pedunculated and foramina!• The latter term 
has reference to the penetration of the last three lumbar cutaneous nerves 
through the deep fascia and through these fascial foramina, the fat globules 
may protrude. Microscopic examination of tissue of all the cases reported 
shows nothing except entirely normal adipose tissue. None showed evidence 
of edema or inflammatory reaction. Nerve tissue was observed in some of the 
sections but the finding is not constant. 
Fair, good and excellent results are recorded in 30 of 32 cases with 
only two failures. The major proportion of these cases gave an excellent 
result* Follow up time is six months to two years and an excellent result 
was obtained in all but seven of the cases. Five of these seven patients 
believe they have experienced enough relief to warrant the operative proce- 
dure and the results were classified as good or fair. One failure was due 
to inadequate work-up and the other failure cannot be explained. 
Gurdjian and Webster (63) report an analysis of 196 cases of herniation 
of the nucleus pulposus operated on between September 19b0 to September 19U6, 
The operative findings in these cases includes lU6 ruptured and protruded 
discs, 28 cases without disc herniation, 9 cases in which 2 discs were found, 
8 massive ruptured discs and 3 calcified discs. Neurological findings were 
either classified as mild or severe. In those patients with severe neurolo- 
gical findings the onset of these changes maybe very rapid in association 
with massive rupture of the intervertebral disc. The operative findings in 
those patients without ruptured intervertebral disc include 12 cases of vari- 
cosities of the outgoing root, 7 cases of root compression by contiguous 
tissue, 1 herniation of cauda equina filament through the dural opening and 
8 normal cases. 
Preoperatively all patients had spinal fluid examinations and in the 
greatest majority the total protein was slightly elevated, the average being 
265 50 mg,$, In only four patients was the total protein above luu mg,$, The 
operative findings and myelographic findings corresponded in 21 cases out 
of 31 in which this procedure was performed. In the remaining 10 there were 
false-positive or negative findings. Every patient had roentgen studies of 
the spine made preoperatively and in 2? of the group significant coexisting 
spinal abnormalities were noted. In 20 patients there was a narrow disc but 
only in seven did this correspond to the affected interspace while in 13 the 
narrowing occurred at other than the affected interspace. 
The operative procedures, as carried out in this study, included bilat- 
eral laminectomy in 23, hemilaminectomy and exposure of the fourth and fifth 
interspaces on the affected side in 121 and combined laminectony at the 
fourth and fifth interspaces on the affected side with fusion of the lumbo- 
sacral spine in 52 patients. The fusion consisted of the use of tibial graft, 
cancellous bone and osteoperiosteal graft. The non-laminectomized side was 
mainly used for the graft. In a few patients the procedure advocated by 
Moore was used, the graft being applied with the patient in flexion to get 
the maximum separation of the vertebrae posteriorly. Most of those patients 
in which fusion was performed were ambulated in approximately two weeks. 
Follow-up studies on 80 cases show only 12$ poor results, with U3$ 
excellent, 25$ good and 20$ fair results. Of the 25 patients fused, results 
include 8$ poor, 2h% fair, 32$ good and 36$ excellent. 
Nine patients had secondary operations with satisfactory results witn 
the exception of one patient in whom a cordotomy was performed as a last 
resort. Among the reoperated patients, material was removed from the same 
interspace in two instances and from another interspace in the remaining 
three, with one patient having a nerve root protruding through a small open- 
ing in the dural sac with a spurious meningocele. Compensation cases have 
not done as well as private ones. There have been little differences In the 
cases in which combined fusion and removal of the disc was performed in com- 
parison to those cases in which simple removal of the disc was accomplished. 
Exploration of the fourth and fifth interspace routinely on the side of the 
pain, as suggested by Dandy, is a satisfactory and a recommended procedure. BIBLIOGRAPHY 
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in a plaster jacket, J. Bone and Joint Surg., 3OB: U87-U89, 19U8 
8. Traeger, C. W.: Fibrositis, arthritis and related conditions, (Bach, 
T. F., Editor), 17U-182, Philadelphia, F. A. Davis Co., 19U7 
9. Hamsa, W. R.: Low back pain-orthopedic aspects, Nebraska M. J., 33: 
210-212, 19U8 
10, Kleinberg, S.: Backache, Bull, M, S. Co. Kings, 27: 220, 19U8 
11, Stuck, R. M.: Differential diagnosis of sciatic pain, Rocky Mountain 
V. J., U5: U77 —U80, 19U8 
12, Moore, A. T.: Traumatic radiculitis in low back pain. Southern M. J,, 
1*1: 1061-106U, 19U8 
13* Baker, L. D.: Marie-Strumpell arthritis and undiagnosed low back 
patient, Nebraska M, J., 33: 331-337, 19^8 
1U« Bach, T. F.: Back pain, arthritis and related conditions, 133-11*6, 
Philadelphia, F. A. Davis Co., 19i*7 
15, Nunziata, A.: Limbosciaticas, El Dia Medico, Buenos Aires, 20: 1691- 
169U, 19U8 
16, GeckSer, E. 0.: Backache, examination and treatment, Hahnemann Monthly, 
83: 237, 19U8 17* West, E# F.j The role of spinal fusion in arthrogenic sciatica; review 
of 52 cases, M, J, Australia, 2: 711, 19U7 
18, Kaplan, A.j Neurofibroma of cauda equina causing recurrent ’’sciatica’* 
for twenty years, Bull. Hosp. Joint Dis., 8: 155-159, 19i*7 
19. Bams, H, H, F.i Backache in women, Practioner, 160; 68-70, 19U8 
20* Moore, A. T, and Cook, W. C.j Lame back with or without sciatica, J. 
South Carolina M* A,, 1*1* s Ul, 19U8 
21. Thiele, G, H.s Painful coccyx; its cause and treatment, K* c« M. J., 
2h: 16-20, 19U8 
22. Salem, E. P.: Low back pain due to narrowing of the intervertebral 
foramen, Bull. Hosp, J, Dis ,, 8: 187-200, 19U7 
23. Cleveland, M., Bosworth, D. M, and Thompson, F. R,j Pseudoarthrosis 
in the lumbosacral spine, J, Bone and joint Surg,, 30A:302-312, 19U8 
2i*, Brav, E, A#, Molter, H, A, and Newcomb, W, J.j Lumbosacral articula- 
tion; roentgenologic and clinical study with special reference to narrow 
disc and lower lumbar displacement, Surg,, Gynec and Obst, 87 s 5U9-560, 
19U8 
25* Little, G, W. E,: Calve's disease of the spine, Proc. Roy, Soc. Med,, 
ill: 262, 19U8 
26, Mes, g* M,s Lumbosacroiliac arthrodesis, J, Inter. Coll, Surg,, 10s 
666-668,* 19U7 
27, Turner, W, W.j Use of Novocaine and oil in the treatment of low back 
injuries, J. M. A, Georgia, 37s 13U-136, 19U8 
28, Roche, M. B.s Bilateral fracture of the pars interarticularis of a 
lumbar neural arch, J, Bone and Joint Surg,, 30As 1005, 19U8 
29, Hirsch, C.j On lumbar facetectomies, Acta Orthcp.Scandinav,, 17s 2k0- 
252, 19U8 
30, Friberg, Sten; Anatomical studies on lumbar disc degeneration, Acta 
Orthop.Scandinav,, 17s 22U-230, 19U8 
31, Parnell, E, and Moore, T,s End results of operative treatment of low 
back pain. Rocky Mt. Med. J., 1*5s 379-382, 19U8 
32, Bradford, F. K,j Intervertebral disc rupture; appraisal of important 
signs, Dis. Nerv, System, 9s 15U-156, May 19U8 33, Spurling, R, G, and Grantham, E, G.: Ruptured intervertebral discs 
in the lower lumbar regions, Am. J, Surg,, 75: li|0-l58, 19U8 
3U. Crisp, E. J.: Treatment of lumbar disc lesions try immobilization in a 
plaster jacket, Rheumatism, h: 211-213, 19U8 
35* Rowbotham, G, F. and Whalley, N.: Low backache, sciatic pain and herni- 
ated nucleus pulposus, Practitioner, 160: 212-220, 19U8* 
36, Potter, J. M.s Protruded disc sciatica in the services and its manage- 
ment, Bull. U. S. Army M. Dept,, 89: Hi3-lU8, 19U? 
37# Lyerly, J, G, and Grizzard, V, t.s Dislocated disc of the lumbar re- 
gion; statistical analysis of series of cases, South. Surg., lU; 755- 
765, 19U8 
38, Falconer, M. A., McGeorge, M, and pegg, A. C.; Surgery of lumbar inter- 
vertebral disc protrusion; study of principles and results based upon 
100 consecutive cases submitted to operation, Brit, J, Sung., 35: 225- 
21*9, 19U8 
39# Lindblom, K*: Diagnostic puncture of intervertebral discs in sciatica, 
Acta Orthqci Scandinav,, 17: 231-239, 19U8 
UO, Caldwell, G, A, and Sheppard, W, B,* Criteria for spine fusion follow- 
ing removal of protruded nucleus pulposus, J, Bone and Joint Surg,, 30Aj 
971-980, 19U8 
1*1* Bakhsh, A,: Ruptured intervertebral disc. Antiseptic, 1*5: l*6i*-U66, 19U8 
1*2, Lj.ndblom, K. and Rexed, B.: Spinal nerve injury in dorso-lateral pro- 
trusions of lumbar discs, J, Neurosurg., 5: 1*13-1*32, 191*8 
1*3. Holscher, E, C,: Vascular complications of disc surgery, J, Bone and 
Joint Surg., 30A: 968-970, 191*8 
1*1*. Shaw, R, S.: Ruptured intervertebral disc from positive acceleration, 
J, Aviation Med,, 19: 276-278, 191*8 
1*5. Dott, N, M,j Lesions of intervertebral disc, Brit. M. J., 2: 9U, 19l*8 
1*6, Raney, R, B. and Raney, A. A,: Consideration of etiology in development 
of ruptured intervertebral disc,, California Med,, 68: 69, 19U8 
1*7. Wilson, C, D.: Diagnosis and treatment of protruded lumbar interverte- 
bral discs, Texas State J. Fed,, 1*1*: khS~Ui*9, 19l*8 
1*8* Black, H, A,: Massive herniation of intervertebral disc producing com- 
pression of the cauda equina, California Med,, 69: 271-271*, Oct, 191*8 ii9. Briggs, H.s Operative aspects of low back pain, J. Med. Soc, of New 
Jersey, U5: 19U8 
50. Kerz, R,; Sciatica caused by cyst formation in old hematomata. Surgery, 
2ii: 71U-718, 19U8 
51. Grant, F. C., Austin, G., Friedenberg, Z, and Hansen, A.: Correlation 
of neurologic, orthopedic, and roentgenographic findings in displaced 
intervertebral discs, Surg,, Gynec., and Obst., 87: 561-568, 19ii8 
52. Friberg, S.x Lumbar disc-degeneration and sciatica, Bull. Schweiz, 
Akad, d, Med, Wissensch,, 3: 269-279, 19U8 
53. Abercrombie, R. G.s Minor signs of displacement of intervertebral 
discs, Ann, Rheumatic Dis., 7: 27, 19U8 
5U. Craig, J. D, and Kessel, A, W, L.: Arthrogenic sciatica and disc pro- 
lapse, M. J. Australia, 1: U18, 19U8 
55. Oldberg, E.j Syndrome of protruded intervertebral disc., Med, Clin, 
North America, 32: li|03-li|13, 19U8 
56. Crisp, E, J,: Conservative treatment of lumbar disc lesions, Proc, Roy, 
Soc, Med,, Uls 261, 19U8 
57. English, R, H, and Spriggs, J, B.: Pain pathways in herniated nucleus 
pulposus syndrome; preliminary report, Mil. Surgeon, 102* 213-216, 19U8 
58. Young, J, H.: Intervertebral disc disease; its recognition and treat- 
ment by general practitioner. New Zealand Med, J., Ii7: 106-llii, 19i|8 
59. Brain, W, R,, Knight, G. C. and Bull, J, W, D.: Discussion of rupture 
of intervertebral disc in cervical region, Proc, Roy, Soc. Med,, ills 
509-516, 19U8 
60. Lewin, P.j Intervertebral disc syndrome, J. Internat, Coll. Surg,, 11: 
137-1U8, 19U8 
61. Kidner, F, C.* Low back pain and sciatica from conservative standpoint, 
Surg, Clin. North America, 28s 1233-12U6, 19U8 
62. Hucherson, D, C. and Gandy, J, R,: Herniation of fascial fat; cause 
of low back pain, Surgery, 76: 605-609, 19U8 
63. Gurdjian, E. S. and Webster, J, E.s Lumbar herniations of the nucleus 
pulposus, Am. J, Surg., 76: 235 —2U3, 19U8 
270 SECTION 12 
CONDITIONS INVOLVING THE THORAX AND DORSAL SPINE 
Prepared by Leroy O, Travis, Major, M. C., U. S. A, 
Posture 
The importance of dynamic posture in reducing fatigue, preventing 
accidents and increasing one's well-being is discussed by Howorth (1). 
The basic dynamic posture is characterized by a slight crouch, with ankle* 
knees, and hips flexed, the head and trunk inclined forward, the arms re- 
laxed, and the trunk and arms slightly flexed. Illustrations show cor- 
rect walking, climbing, sitting, reclining and lifting. 
Anomalies 
Torgerson (2) presents radiological evidence of the association of 
lumbosacral defects with anomalies of the coccyx, kidneys and lower in- 
testinal tract in 2 cases; of hemispondylos, kyphoscoliosis, defects in 
an arch of a vertebra or hypoplasia of a vertebra with inversion of vis- 
cera in seven cases; and of anomalies of the spine with constitutional 
peculiarities of an endocrine nature in 2 cases. The observations seem 
to indicate a developmental relationship stemming from the primitive no- 
tochord. Similar observations have been made in amphibia and short-tailed 
mice. 
The various anomalies observed in the study of 1?0 radiograms of 
normal individuals (adult Indians) and 12 skeletons are presented by 
Glnde and Kurulkar (3). Some type of anomaly was present in 66.3$$ spina 
bifida occulta was observed in 20.6$ of the cases; a total incidence of 
6% of cases of cervical ribs was observed in the roentgenological studies. 
Brodkin (U) presents a case (11 year old girl) of congenital chon- 
drosternal depression, another term suggested for "funnel chest", relieved 
by chondrosternoplasty. He believes it to be a congenital deformity due 
to a short central tendon of the diaphragm. The indications for operation 
are given as (l) disturbance of cardiac function (operation delayed in his 
case because signs and symptoms suggested rheumatic fever) and (2) unfa- 
vorable effect on the emotional state of the patient, particularly girls. 
A prophylactic operation, as described by Brown, for young infants is des- 
cribed, as well as the plastic procedure of elevating the sternum by trac- 
tion using silver wires at the angle of Ludwig and the lower end of the 
gladiolus• 
Tumors 
Although early diagnosis of tumors of the rib cage is relatively 
simple, their removal is frequently delayed until they have undergone mal- 
ignant degeneration. Poppe and Berg (£) present 2 cases of osteochon- dromata operated upon before sarcomatous degeneration* Roentgen therapy 
is recommended for the occasional Ewing's sarcoma or multiple myeloma of 
the ribs, but for osteoplastic metastatic carcinoma surgical removal will 
often relieve local symptoms for many months. A radical resection, fre- 
quently including 3 ribs and parietal pleura (if tumor overlies the free 
pleural space) must be done. A practical technic is described for closure 
of the rib cage defect by overlapping the adjacent ribs. 
Chest Closure 
In order to meet the problem of a satisfactory closure of the chest 
wall after thoracic surgery, Naclerio (6) has proposed a clip-on subperi- 
osteal band to go around the adjacent ribs. The stainless steel bands are 
made in £ lengths which are quickly placed beneath the periosteum so as 
not to impinge on the intercostal nerves. The patient can move about safely, 
comfortably and freely immediately after operation. 
Sternochondral Joints 
The stemochondral joints from several hundred cadavers were examined 
by Gray and Gardner (7) revealing the presence of fibrocartilage in all of 
these joints, and an interarticular ligament in the second joint in less 
"than half the cases. The fibrocartilage, not present at birth, obliterated 
the cavity of the joint either partially or entirely, or formed strands 
which usually passed obliquely across the cavity. It seems likely the 
fibrocartilage arises in response to the unusual mechanical stresses of 
the repetitive and multi-directional movements at these joints. 
Scheuermann's Disease 
Knutsson (8) has, by serial roentgenograms on cases of Scheuermann's 
disease, using the nucleus pulposus as a marker, demonstrated that hori- 
zontal growth takes place by means of an appositional growth from the an- 
terior surface of the vertebral body. Vertical growth may be inhibited by 
the disease, resulting in a sagittal or frontal wedge shape in the localized 
type, or an intact but flattened rectangular shape in a more uniformly dis- 
tributed process. In all cases the diseased vertebrae have augmented sa- 
gittal depth. 
Scoliosis 
The subject of scoliosis is reviewed by Ryan (9) in a lecture as 
part of a refresher course. He covers the history of scoliosis, its 
classification, embryology, anatomy, diagnosis and treatment. He traces 
the history of scoliosis from Hippocrates to the late 19th century. The 
principles of extension, derotation and lateral correction still form the 
basis of treatment. He gives two classifications and some contributing 
factors to be considered. He describes in detail the embryology of the 
vertebral column as it develops through mesodermal changes about the noto- 
chord, to help explain the anatomical variations which arise. The blood supply to the vertebrae is also discussed as a source of the bony abnor- 
malities. The gross anatomy and physiology of the sjctions of the spinal 
column are presented as they apply to the production of scoliosis. 
Rarely can a diagnosis of scoliosis be suspected until the child as- 
sumes the erect position, and even so in Q0% no cause will be found and 
an inherent muscle weakness or mild central nervous system lesion must be 
assumed. 
He emphasized the differentiation between the primary and the secon- 
dary curve as a prerequisite of treatment. The primary thoracic curve may 
be symptom-free in the older patients, while the more mobile secondary 
lumbar curve produces distress due to continued muscle strain and the on- 
set of arthritic changes in the spine. Although treatment is admittedly 
not ideal, satisfactory correction can be obtained in the clothed indivi- 
dual. The first stage in treatment is an attempt to mobilize the spine 
and to develop the muscle tone by exercises and manipulation. Where any 
known etiological factor is present and active it must be corrected pri- 
marily. The apparatuses which have been devised to assist in correcting 
the deformity are discussed, including the author's derotating chair. Later 
plaster jackets may be used, with exercises as described by many au- 
thors. To maintain correction, fusion of the spine is usually necessary. 
Fusion of more than seven vertebrae should not be undertaken at one stage. 
In children, he recommends fusion when the ossification in the vertebrae 
has progressed sufficiently to maintain the correction. This may be ac- 
complished when X-ray films indicate complete attachment of the iliac 
crest throughout its length to the ilium. 
In order to assist in the mechanical correction of scoliosis prelim- 
inary to fusion, Scudese (10) suggests a lateral flexion apparatus on 
which the patient is placed for casting. The cast may be windowed for 
operation. The apparatus consists of 2 adjustable turnbuckle troughs 
firmly hinged to a bar which fits into the pelvic rest of a fracture 
table. The patient is placed on the apparatus with the apex of his curve 
directly over its apex. Roentgenograms are used to check correction of 
the deformity. A plaster is applied from head to knee on the convex side 
of the body, from head to greater trochanter on the concave side and cov- 
ering both arms to the elbow. 
The medical complications of kyphoscoliosis are well presented by 
Bland and Goetz (11) with reference to a U5 year old woman who had severe 
scoliosis secondary to poliomyelitis at 6 months of age. She was being 
studied for cardio-respiratory symptoms in preparation for surgery for 
carcinoma of the breast. Previous cases who died of lung failure before 
heart failure and some following the giving of morphine are discussed. 
One case was relieved by walking on all fours "like a bear" and another 
was relieved by hyperextension in bed. In these cases the primary fault 
is in the thoracic cage which cannot inflate the lung adequately, resulting 
in a sort of "thoraco-cardiac failure" usually with dilatation of the right 
heart. Some have lived to the fifties or sixties but the averafe/of death 
is 30 years. Digitalis in these cases has no virtue. They may develop 
psychoses due to lack of oxygen. Adequate oxygen and even artificial res- 
piration will help keep these patients alive but some go into acute ir- reversible failure despite all efforts. Surgery is debatable on spines 
with such long-standing deformity that cardio-respiratory symptoms are 
pronounced• 
Os te omyelitis 
Two cases of vertebral osteomyelitis secondary to lumbar paraverte- 
bral novocain block are presented by Brown and Hoffman (12). Apparently 
these are the first two such oases. Both were battle casualties. The 
blocks were administered for pain and coldness of the limb due to posterior 
tibial nerve severance in one, and to severance of the posterior tibial ar- 
tery and vein in the other. The cases are described in detail and the dif- 
ferential diagnosis between pyogenic and tuberculous osteomyelitis of the 
spine presented. In both cases there was an acute, more or less febrile on 
set after the blocks with persistent back pain and paravertebral spasm. 
Bony destruction with evidence of new bone formation occurred early, with 
ultimate fusion between the 1st and 2nd and the 2nd and 3rd lumbar verte- 
brae in 5 and 10 months respectively. Symptomatic relief was obtained by 
the application of plaster fixation. Both cases received penicillin and 
eventually recovered. 
Mayer (13) presented a case to the Royal Society of Medicine with 
apparently a double pathology: (a) old vertebral epiphysitis previously 
undiagnosed involving L2 in a 25 year old male, and (b) subcutaneous ab- 
scess of the back arising in the same area by hematogenous or lymphatic 
spread from a recent furuncle over the right scapula. Under local and 
systemic penicillin therapy with aspiration of the abscess, the acute py- 
rexia and superficial lesion cleared up, but X-ray findings were unchanged. 
The sclerosis and new-bone formation seen in X-rays 10 days after the onset 
of symptoms are not consistent with a diagnosis of staphylococcus osteomy- 
elitis of a vertebra. 
Paraplegia and Soft Tissue Ossification 
Abramson (1U) has analyzed the relationships between bone atrophy, 
urinary calculi and soft tissue ossifications in 56 cases of paraplegia. 
These ossifications never occur above the level of the lesion. In his 
cases the blood serum calcium,, phosphorus and phosphatase were normal. 
Ambulatory patients were considered those who had walked for at least 
two years for an hour or more nearly every day. Most patients led a 
wheel-chair existence and had an aversion to ambulation. There was a 
striking difference in the incidence of calculi, osteoporosis and soft 
tissue ossification in the two groups. The earlier the ambulatory ones 
started walking, the lower was the incidence of these complications. 
Only eight cases fit the ambulation category. It was felt that the presr- 
sure on the bone in ambulation produced bone matrix, thus allowing the 
deposition of calcium in the bone, and not in the urine and soft tissues. 
The only logical therapeutic agent which applies pressure intermittently 
is ambulation. Active, passive exercises and massage had no influence 
on the bone atrophy. Backache 
The thoracolumbar syndrome is described by Jacobs (15) as a common 
cause of backache. The thoracolumbar spine, because of certain mechanical 
and anatomical factors, which are described in detail, is susceptible to 
frequent strain and irritation. Irritation of the 12th thoracic or first 
lumbar segments may produce symptoms simulating sacro-iliac and lumbosacral 
pain, or any of several urologic, gynecologic or surgical problems. The 
consistent objective findings in this syndrome include: 1. The pain may 
involve the 11th thoracic thru 1st lumbar segment unilaterally or bila- 
terally and is very variable in intensity and duration. 2. Hyperesthesia 
as well as tenderness on deep palpation over th.r trunk of the involved 
nerve may usually be elicited. 3. There is invariably limitation of spi- 
nal motion and some scoliosis. X-rays taken with the patient standing 
show the depressed twelfth rib, lumbar scoliosis, pelvic tilt, and inter- 
nal rotation of the head of the femur on the side of the low crest of the 
ilium. The most effective method of therapy is perineural injection of 
procaine by the technique described, associated with the correction of ob- 
vious postural defects. 
The intervertebral ligaments have been further studied experimentally 
as a source of segmental pain. Sinclair et al (16), using human volunteers, 
injected saline into and around the intervertebral ligaments with X-ray con- 
trol to ascertain the exact location of the point of the needle. In the 
thoracic region injections as nearly as possible to the midline caused re- 
ferred pain much less readily than injections to one side. In the lumbar 
region injection of as much as 0.6cc of hypertonic saline into the midline 
caused only local pain in the back and failed to cause referred pain. It 
was assumed that referred pain was caused by direct stimulation of the 
nerve trunks and not by stimulation of the interspinous ligaments as pro- 
posed by Lewis and Kellgren, whose views are presented and discussed at 
length. 
Industrial backaches were studied in 90 consecutive cases by Loopesko 
(17). Adequate treatment by progressive fascial ligamentous loosening was 
given to 77. Patients were released after an average of 10.2 days with 
5.2 treatments, and only one case required hospitalization. All went back 
to full duty. Two thirds had no lost time. Most cases complained of low 
back pain, but there were also cases of cervical, dorsal and upper lumbar 
area strains, some being brought in by ambulance because of their severity. 
The proper psychological handling and instruction of patients being so 
treated is most important if patients are to adhere to the treatment and 
receive its benefits. The rationale of the treatment is based upon the 
theory that peripheral nerve irritation may be produced by outside compress- 
ion, as by contracted fascial ligamentous bands. The technique includes 
active exercise by the patient and passive stretching by the surgeon, under 
short relaxing anesthesia if necessary. Passive stretching includes straight 
leg raising in adduction past 90 degrees, and hyperextension in adduction 
and sbduction, just a little beyond the point of definite resistance, with 
care to prevent nerve damage. He urges institution of the regime immedi- 
ately after an industrial injury likely to produce backache by excessive 
strain causing tear of fascial fibers. In a plant cited, lost time due to 
such injuries had been reduced practically to zero. Noble (18) studied 10k cases of painful back in a Veteran*s Hospital 
in Canada, The average age was 33 years. The etiology of the backaches 
ranged from postural and traumatic strains, bone injuries, spondylolis- 
thesis, tuberculosis and ankylosing spondylitis to intervertebral discs 
treated conservatively and operatively. He discusses specific exercises 
and immobilization, and summarizes the results of treatment. He concludes 
that when a protruded intervertebral disc can be diagnosed, operation may 
not necessarily restore the laborer to normal activity: 2 of 16 returned 
to full duty. He emphasizes that the patient with recurring traumatic 
strain may be in the early stages of a disc lesion. This study indicates 
the value of the lumbosacral brace, particularly in those cases who have 
had a laminectomy without fusion and who have residual back symptoms, A 
study of the nature of the trauma resulting in chronic back pain suggests 
that the best treatment may be prevention by postural training, particularly 
in the military and industrial establishments, to assist in overcoming the 
human constitutional weakness at the lumbosacral junction. BIBLIOGRAPHY 
1. Howorth, M. B. * Dynamic posture, J. Health and Phys. Educ., 18: 701*- 
706, Dec. 191*7 
2. Torgerson, J.s Anomalies of spine in anomalies of viscera and consti- 
tution, Acta Radiol., 29s 311-320, 191*8 
3. Ginde, R. G. and Kurulkar, L. N,: Anomalies of spinal part of axial 
skeleton and costal cartilages, Indian Physician, 7: 212, Aug. 191*8 
1*. Brodkin, H. A.: Congenital chondrosternal depression (funnel chest) 
relieved by chondrosternoplasty. Am. J. Surg., 75: 716-720, May 191*8 
5. Poppe, J. K. and Berg, R.s Resection of chest wall tumors; report of 
two cases, Northwest Med., 1*7: 119-122, Feb. 191*8 
6. Naclerio, E. A.: Subperiosteal periocostal band for thoracic cage 
approximation. Am. J. Surg., 75: 859-861, June, 191*8 
7. Gray, D. J. and Gardner, E. D.s Sternochondral joints in man, J. 
Michigan M. Soc., 1*7: 301*, Mar. 191*8 
8. Knutsson, F.s Observations on growth of vertebral body in Scheuer- 
mann's disease, Acta Radiol., 30s 97-101*, Aug. 191*8 
9. Ryan, C. A.s Scoliosis, Canad. M. A. J., 58: 170-171*, Feb. 191*8 
10. Scudese, V. A.: Rapid method of correcting deformity in scoliosis 
preliminaiy to fusion, J. Bone and Joint Surg., 30A: 980, Oct. 191*8 
11. Bland, E. F. and Goetz, F. G.s Kyphoscoliosis, Am. Practitioner, 
2; 761-765, July 191*8 
12. Brown, R. and Hoffman, B. P.s Osteomyelitis of spine secondary to 
paravertebral block. Bull. U. S. Army Med. Dept., 8: 391-396, May 
191*8 
13. Mayer, J. H.s Caries of spine; for diagnosis, Proc. Roy. Soc. Med., 
1*1: 571, Sept. 191*8 
li*. Abramson, A. S.s Bone disturbances in injuries to the spinal cord 
and cauda equina (paraplegia); their prevention by ambulation, J. 
Bone and Joint Surg., 30A: 982-987, Oct. 191*8 
15. Jacobs, J. E.: Thoracolumbar syndrome as common cause of backache. 
No. Carolina M. J., 9: 122-126, Mar. 191$ 16. Sinclair, D. C. and Feindel, W. H.s Intervertebral ligaments as a 
source of segmental pain, J. Bone and Joint Surg.,30B: 515-521, 
Aug. 191*8 
17. Loopesko, E.s Treatment of industrial backaches by progressive fas- 
cial ligamentous loosening. Industrial M., 17: 329-332, Sept 191*8 
18. Noble, J. A.: Series of cases of painful back, Canad. M. A. J., 
1*73-1*78, May 191*8 SECTION 13 
CONDITIONS INVOLVING THE HIP JOINT 
Prepared by Alfred H. Bungart, Lt. Col,, MC, U.S.A, 
Coxa Plana 
In discussing pseudocoxalgia, Korvin (1) feels that the pathological 
process in the femoral epiphysis is one of aseptic necrosis and not of some 
infectious process. 
Waldenstrom's sign - (an increased distance between the medial pole 
of the head and the floor of the acetabulum) - was commonly noted very early, 
even before any fragmentation could be observed on x-ray. Associated with 
this sign it is observed that there is an alteration of the contour of the 
acetabular floor which appears to be abruptly hollowed out. Experimental 
work has led to the conclusion that both Waldenstrom's sign and the altera- 
tion of the acetabular floor are the result of pressure from a markedly 
swollen and edematous ligamentum teres. 
In some instances, cyst-like areas of absorption may be observed in the 
neck and acetabulum. These are usually attributed to an extension of the 
osteochondritis. The author opposes this theory and feels it is part of the 
process of osteoporosis and is seen in other states such as osteoarthritis, 
rheumatoid arthritis and osteomalacia in which osteoporosis is a feature. 
The cyst-like areas heal spontaneously with the healing of the underlying 
pathology, i,e. when the epiphysis regains its normal texture. 
The amount of deformity undergone by the femoral epiphysis before it 
regenerates is the main factor in determining the ultimate shape of the up- 
per end of the femur. However, this is not the only factor. Deformity of 
the femoral neck may develop very early in the course of the disease, even 
before appreciable deformity of the head. Some cases present on x-ray, a 
tilting of the epiphysis due to a forward bending of the neck before any 
real deformity of the epiphysis itself can be detected. These constitute 
Legg's mushroom type with a favorable prognosis. The author attributes the 
bending of the neck to an osteoporosis. 
Although it is generally considered that there is no pathological change 
in the articular cartilage, the author found an early pathological change in 
S% of his 102 hips studied, 
A brief review of the history of the osteochondral conditions of the 
hip is presented by Graham (2), It would appear all of these conditions 
have the one thing in common, of disturbance in the blood supply to the 
head of the femur. The author describes the blood supply to the head of the 
femur as being from three sources: arteries in the ligamentum teres; vessels 
in the capsule, especially in posterior capsular arteiy; and vessels enter- 
ing the head from the marrow. In the case of congenital dislocation of the hip the blood supply from the ligamentum teres is absent and the most im- 
portant source is through the capsular arteries. A brief review of the 
classical symptoms and physical and x-ray findings is given for congenital 
subluxation and dislocation of the hip, for Legg-Perthes1 disease and for 
slipped capital epiphysis. In the review of treatment, the author favors 
long continued traction and recumbency in the treatment of Legg-Perthes1 
disease; open reduction in true congenital dislocation of the hip and the 
use of the Smith-Petersen nail after replacement or wedge osteotomy in the 
case of slipped capital epiphysis, Four cases are presented as illustrative 
of the points mentioned* The main theme of the paper is the author's plea 
for earlier and more adequate treatment of these childhood conditions in 
order to prevent the complications which invaribly follow, 
Draznin and Singer (3) report a case of a five-year-old-white female 
found to have Gaucher's disease. A splenectomy was done to prevent bleed- 
ing. The child made an uneventful recovery. She was followed closely and 
at the age of ten was found to have typical signs and x-ray findings of 
Perthes' disease. At the time of her marriage at the age of twenty-one, she 
was again examined. She had a good blood picture but some enlargement of 
the liver. On x-ray she had the typical deformities of Perthes' disease 
with bilateral flattening of the femoral heads, severe coxa vara and areas 
of radiolucency and sclerosis of the femoral heads, necks and proximal 
shafts. In addition she had the typical x-ray changes of Gaucher's disease 
in the lower end of the femora consisting of the Erlenmeyer flask appear- 
ance with widening of the medullary cavities, thinning of the cortices, and 
numerous areas of radiolucency in the shaft. 
A review of the past and present theories as to the etiology of Legg- 
Calve-Perthes' disease is presented. The authors feel that the condition 
now referred to as Perthes' disease may be a manifestation of one or more 
conditions, such as Gaucher's disease and although a given case may prove 
to be a pure hip joint process, every effort should be made to rule out any 
other condition. In other words, Legg-Calve-Perthes' disease is very often 
not a definite clinical entity but rather a syndrome of many etiologies. 
Such factors as trauma, infection, endocrine dysfunction, vascular accidents, 
etc., must also be considered as etiologic agents. Much work remains to be 
done before the final pages are written on this obscure condition. 
Based on the theoiy that the basic pathology of Legg-Perthes' disease 
is an aseptic necrosis on the basis of deficient circulation, Zadek and 
Berkett (U) have attempted to encourage and facilitate the revascularization 
by multiple drillings into the involved area. Ten cases are presented and 
reviewed. The drillings were carried out either by arthrotomy and retrograde 
drilling or from the side, much as one inserts a guide wire for nailing of 
a hip. Postoperatively the patients were kept from weight bearing by one or 
more of the usual means such as recumbency, traction, cast or caliper brace. 
The follow-up period ranged from two to twelve years. The conclusion of the 
author is that no alteration in the course or end result was obtained from 
the surgery. There was no shortening of the length of the regeneration pro- 
cess and no ill effects were noted. The results of the study lend credence 
to the theory proposed by Legg, that there are really two types of the dis- 
ease, one in which the head becomes flattened and mushroomed centrally, and 
the other in which there is a tendency toward flattening associated with 
2So; more fragmentation and migration of the flattened head toward the greater 
trochanter, Legg felt that the eventual outcome depended for a great part 
on the type encountered regardless of weight bearing or recumbency. 
Haythorn (5) reports a study made of the material obtained from the 
curettings from the head and neck of the femur of thirty-one cases of Legg- 
Perthes' disease. All cases showed essentially the same pathological pic- 
ture, varying only in the degree and amount of change. Constant findings 
were aseptic necrosis, compression of the various bone elements, and incom- 
plete healing process which was going on concurrently and to little purpose. 
The necrosis involved all the tissues present to varying extents and included 
destruction of marrow with bony trabeculae recognizable but without nucleated 
osteocytes or osteoblasts. Cartilage showed fragmentation, degeneration and 
imperfect ossification. Intermingled with the degenerating areas were islets 
of healing including simple fibrous replacement of marrow stroma which was 
infiltrated sparsely with lymphocytes and occasional leukocytes. Areas of 
osteogenesis and osteoclysis were jumbled together and the normal line of 
ossification of the epiphyseal cartilage was lost. The lesions are thought 
to be due to nutritional disturbances associated with vitamin and growth 
hormone deficiencies. 
In a discussion of early coxa plana, Stahl (6) states that the exact 
age of onset is difficult to determine for there is always a period of vague 
symptoms prior to the time the patient seeks medical aid. Also it appears 
that there may be a period in which the process is active before the symp- 
toms even in the mildest form appear. The earliest x-ray evidence is flat- 
tening of the anteriorposterior contour of the capital epiphysis and an in- 
crease in the distance between the ccmtour of the head of the femur and the 
acetabulum (Waldenstrom’s sign), Brailsford is of the opinion that the pro- 
cess has existed for Itwo to three months prior to the time that these x-ray 
findings are noted. The most common age at which the condition is brought 
under medical attention was six years; the average patient had noted some 
symptoms of the condition for one year prior to the original examination. 
Of the cases studied there was an average of sixteen months existence of the 
condition before x-ray evidence of repair could be detected and the condi- 
tion took an average of three years for total repair. It was the general 
feeling of the author that the process of repair was somewhat more rapid the 
younger the patient was at time of the onset. 
Slipping of Capital Femoral Epiphysis 
A number of papers on the subject of slipped capital femoral epiphysis 
appeared in the orthopaedic literature during 19U8, Generally speaking 
there was an unanimity of opinion concerning the treatment of this condition, 
Badgley, Isaacson, Wolgamot and Miller (7) gave five postulates which have 
'Been their yardstick for the treatment of this condition. These arej 
1. A displacement of not more than one third of the diameter of the 
femoral epiphysis has been accepted as a satisfactory position. These cases 
as well as those which show even less displacement are treated by internal 
fixation without any attempt at alteration of the position of the epiphysis , 2. Displacement of the upper femoral epiphysis beyond this extent, 
usually associated with deformity and disability, requires improvement of 
the position of the epiphysis in its relation to the neck. 
3. Skeletal traction had been used for the reduction of the displace- 
ment. Should a satisfactory reduction result, its maintenance by internal 
fixation until the femoral epiphysis had closed has been the most successful 
method of treatment. The acute traumatic type or the chronic slow form sud- 
denly complicated by trauma will usually be corrected by this method. 
h. Unsuccessful skeletal traction necessitates open reduction of the 
displaced epiphysis. Not infrequently removal of a wedge of bone anteriorly 
has been required in order to attain the proper alignment. It is advisable 
to maintain the position thus gained by means of internal fixation. 
5* The ultimate fate of the neglected and displaced upper femoral epi- 
physis is most certainly degenerative arthritis. Correction or prevention 
of the displacement has been the rule of therapy. The subtrochanteric or 
intertrochanteric osteotomy has been reserved for the patients with the mal- 
united, fused upper femoral epiphysis and a hip that has maintained fair or 
good motion but has external rotation deformity. 
The main theme of the entire paper is the early recognition and internal 
fixation of the slipping before the later and damaging stages of the condition 
can be reached. It is considered far better to attack the condition in the 
later stages by an osteotomy of the neck in the region of the epiphysis than 
to resort to the trochanteric osteotomy, for in the latter case no correction 
of the original and basic pathology is attempted and the mechanics of the 
hip are still in the altered state* 
Seventy-eight hips are reviewed in light of the methods advocated for 
treatment of the various stages of the condition. In the older cases requir- 
ing wedge osteotomy and internal fixation for correction, 56$ obtained ex- 
cellent results and 32$ poor results. In open reduction without internal 
fixation, 36$ obtained excellent results and U6$ poor results. Open reduction 
without wedge and with internal fixation produced 50$ excellent results and 
25$ poor results. Closed reduction with internal fixation showed 83$ ex- 
cellent results and 17$ poor results. Internal fixation without attempted 
reduction had 69$ excellent results and 25$ poor results. Subtrochanteric 
osteotomy showed 50$ excellent results and 25$ poor results. The unaccounted 
cases in the statistics ranged from good to fair results. 
The major complications noted in the operative procedures for the 
correction of this condition are traumatic arthritis and aseptic necrosis. 
Only h% of the hips operated revealed x-ray evidence of aseptic necrosis; 
2k% revealed x-ray evidence of traumatic arthritis • This latter condition 
developed in two patients in which no therapy had been attempted and in two 
in which blind nailing was done. It would appear that the operative procedure 
is not the only factor in the production of this complication and that some 
intrinsic predisposition exists toward such a complication. 
The generally conceded poor results in the treatment of slipped femoral 
epiphysis is re-emphasized by Martin (8) and the blood supply to the capital epiphysis is presented for clarity. During the preceding seven years 
twenty-six patients have been treated and from these certain conclusions 
are drawn. It is felt that closed reduction should be condemned except in 
the unusual case of the acute displacement of less than two weeks duration. 
Even then only the most gentle manipulative reduction is permitted, consist- 
ing of gentle traction and internal rotation and if successfully reduced b; 
this means the epiphysis should immediately be fixed by a Smith-Petersen 
nail. If the slipping has been more gradual or of more than two weeks dura- 
tion, open reduction should be performed without any attempt at closed mani- 
pulation. The open reduction advocated by the author has as its watchword 
GENTLENESS, No attempt should be made to lever the head onto the neck, but 
instead a wedge osteotomy is performed with the base of the wedge superior 
and anterior and just distal to the epiphyseal plate. The neck of the femur 
is then carefully brought into alignment with the proximal epiphysis and a 
Smith-Petersen nail' inserted over a guide wire t6 fix the fragment. It is 
emphasized that care must be exercised in opening the capsule in the superior 
aspect and that the periosteum must be carefully preserved about the neck of 
the femur and when the operation is concluded reattached to the bony structure. 
The procedure has been utilized on seven patients in whom the follow-up has 
been sufficiently long to draw final conclusion. Of this group six have been 
classified as excellent. The seventh patient has limitation of motion and 
a marked limp but it is felt that this failure was due to the fact that the 
nail was driven through the head at the time of the fixation and the patient 
used the leg sufficiently to produce damage to the acetabulum* It is not 
due to any failure in the principle advocated but purely to a technical 
error. 
Sten Friberg (9) reports that seventy cases of slipped capital epiphysis 
which were nailed with the usual three flanged nail before more than one 
third slipping had occurred gave very good results. The rule upheld by many 
other authors is reiterated i,e, if there is more than one third of the 
epiphysis displaced, open reduction is indicated. The author has performed 
the wedge osteotomy, generally advocated, on thirteen cases with more than 
one third slipping. The wedge is classically removed at the epiphyseal 
line with the base superior and anterior and the head replaced and held by 
a three flanged nail. It is felt that the use of a guide wire facilitates 
the nailing by preventing the tendency for separation of the osteotomy line 
when the nail is driven. In the thirteen cases reviewed, twelve are suffi- 
ciently followed for appraisal. Ten of the twelve have excellent results; 
one case presented a total necrosis of the head which was noted prior to 
surgery, in one case there was a partial necrosis which disappeared. 
Seventy-three cases of slipping of the capital femoral epiphysis are 
reviewed by Ponseti and Barta (10) in the light of treatment and the end 
results of such treatment. The cases were in different stages of displace- 
ment and were divided into five groups depending upon the amount of the 
displacement. The ages of tiie patients varied from eleven to seventeen years 
in boys with an average age of XU,1 years. In the girls the age varied from 
ten to fourteen years with an average age of 12,1 years. Interestingly 
enough, one boy with bilateral displacement and one girl with unilateral 
slipping were age twenty and twenty-five respectively and both cases were 
complicated by deficiency of the pituitary growth factor and closure of the 
epiphysis had not yet occurred. In the pre-slipping stage where there was little if any deformity the 
treatment of choice was found to be drilling of the epiphyseal line in a 
manner similar to insertion of a Smith-Petersen guide wire. The drilling 
was then followed by pinning. 
In cases suffering from acute slipping or fracture through the epiphy- 
seal line, the best results were obtained in those who were seen immediately 
after the injuiy, In these cases, very gentle reduction followed by internal 
fixation by means of threaded Steinmann pins gave good results. If the 
accident was as much as two weeks old, it is inadvisable to attempt reduction, 
for the percentage of avascular necrosis of the epiphysis is extremely high. 
Chronic slipping with minimal or moderate displacement: No attempt 
was made to reduce the displacement. Very good results were obtained by 
either simple avoidance of weight bearing, prolonged immobilization in plas- 
ter or by drilling followed by pinning of the epiphysis. In those treated 
by simple immobilization, nine months was the average time for closure of 
the epiphysis while those which were subjected to drilling and pinning closed 
in six months time. The internal fixation method has the additional advan- 
tage in assuring against an acute slipping from trauma. 
Chronic slipping with marked displacement: From the present survey it 
is obvious that no matter what the treatment, the prognosis is poor. By 
drilling the epiphyseal plate and pinning the epiphysis, further displacement 
is’prevented but an osteotomy is required to restore the proper weight bear- 
ing line. In the series presented, various types of osteotomies including 
cuneiform and subtrochanteric were used but the results were discouraging. 
Residual deformities of the femoral head and neck due to old slipped 
epiphysis: All patients of this group complained of hip pain and had marked 
limitation of motion. The prognosis is grave in such cases and the only 
consideration is that of some type of arthroplasty or arthrodesis of the 
hip. 
Mearns (11) reviews twenty-five cases (thirty hips) of slipping of the 
upper femoral epiphysis in the light of symptoms and diagnosis. The classi- 
fication of the amount of displacement as seen on the AP and lateral x-rays 
is classified as: MINIMAL when the anteversional shift is less than one cm, 
and there is no vertical displacement; MODERATE cases with one cm. or more 
of anteversional shift but with slight or no vertical displacement; SEVERE 
displacements, those showing obvious displacements. 
In the classification of the results the following criteria were used: 
Good, no pain or limp and a range of motion that does not in ary way restrict 
normal activity; Fair, no pain and only a mild limp but with a limitation 
of the range of motion great enough to prevent participation in sports requir- 
ing running; Poor, pain on exertion or severe limitation of motion and short- 
ening , 
It is interesting to note that the frequency of involvement of the two 
hips was essentially equal but that the condition was found three times as 
commonly in the male as in the female, {lG% male and 2lx% female), Theftvast 
majority of the cases were of the obese type and tending toward the Frohlich 
build. No mention is made of the type of treatment employed but in the survey 
of final results, of the seven cases classified as minimal, all obtained 
good results. Of those classified as moderate slip (seven hips) only four 
could be classed as good and three as fair. Finally, of the sixteen hips 
in the severe displacement category, none could be classed as good, seven 
as fair and the remainder as poor. There is a direct relation between the 
outcome and the amount of slipping and, by the same token, to the prompt- 
ness of diagnosis. Of the entire group the average age at the onset of 
symptoms w as 13 ,5 years and the average duration of symptoms at the t ime of 
treatment was 8,5 months. All too frequently the admitting history was one 
of a child who developed mild pain without cause and a slight limp. He 
would be seen and x-rays made and the true pathology missed. The child's 
activities would be restricted and the symptoms would decrease. However, 
in a short period there would develop an exacerbation of the symptoms but 
with greater severity and the cycle would be repeated. 
Mearns attempts to drive home the point that any child of the age group 
involved who develops pain in the hip either with or without injury should 
have a careful examination and thorough x-ray studies including the lateral 
view of the hip for it is on this projection that the early displacements 
can be found. It has been well shown that the so-called widening of the 
epiphyseal line is the result of anteversion which projected in the roent- 
genograph gives the impression of widening. The results of treatment of 
slipping of the upper femoral epiphysis are uniformly good when the diag- 
nosis is made in the minimal slipping stage and the prognosis progressively 
more unfavorable corresponding to the severity of the displacement. 
Samson and Jerry (12) report eight early cases of slipped epiphysis 
treated l>y Leadbetter reduction with plaster immobilization for three months 
using a Steinmann pin through the femoral condyles. In follow-up from nine 
months to three years the average shortening was J to 2 cm, There was nor- 
mal function in six cases, slight limitation of flexion in one case, and 
only one case of aseptic necrosis. Vive late cases were treated by osteotomy 
with Steinmann pin or Blount blade-fixation. Four results were excellent 
and one fair. 
Fischer and Leatherman (13) review the classical signs and symptoms of 
slipping of the capital epiphysis, emphasizing the often found early complaint 
of discomfort in the lower thigh and knee. Too many times x-rays are made 
of the knee and found normal and the patient dismissed. At that early period 
one has the optimum time for treatment of an early slipped femoral epiphysis. 
The etiology of the condition is unknown. Some are associated with 
trauma, A striking number of the patients are obese, hypogonadal types of 
children. 
Several types of treatment are reviewed. Some authors prefer merely 
plaster fixation in the early stage, i.e. with slipping of less than one 
third of the diameter of the neck, while others advocate fixation by means 
of a Smith-Petersen nail with no attempt at reduction. In the later cases 
with considerable displacement it is necessary to surgically replace the 
epiphysis, fixing it with a Smith-Petersen nail, A plea is made for early 
recognition, when the epiphysis is in the so-called "pre-slipping" stage and 
has migrated less than one third the diameter of the femoral neck. These 
early cases offer a good prognosis. Hip Lesions in Childhood and Other Conditions 
Hip lesions of infants and children seen at the Newington Home and 
Hospital for crippled children were reported by Heublein, Bernstein and 
Hubenet (Hi). They review embryological development of the hip and the 
relation of defects during the embryo stage to the deformities considered 
as congenital deformities as seen in the usual clinic for children. The 
importance of early diagnosis of the congenital conditions in relation to 
treatment and final outcome is stressed* 
The various theories of the origin of congenital dislocation of the hip 
are noted and of the seventy-seven cases treated at the institution, the 
majority were in the female. Almost one third of the cases were bilateral. 
Forty cases were treated by closed reduction and thirty-seven by open reduc- 
tion. 
In the instance of congenital dislocation associated with arthrogryposis 
multiplex congenita, it is of interest that in this disorder quickening may 
occur late in pregnancy or be absent altogether. A presumptive intra- 
uterine diagnosis can be made on the basis of such a history and roentgen 
demonstration of the fetal extremities fixed in a position of extension. 
The authors find that the incidence of congenital dislocation of the 
hip associated with spina bifida is quite rare. 
Dislocation of the hip occurs in association with infective lesions of 
the hip and with infantile paralysis. 
In cases of Legg-Perthes» disease, the authors review the literature 
and find the usual clinical and roentgen picture. It is noted that the 
widening of the epiphyseal line is of importance in early diagnosis. Fifty- 
nine cases of Perthes* disease have been treated during the previous twelve 
years. The average age at onset was eight years and males predominated over 
the female four to one. 
The classical picture of slipped femoral epiphysis was noted in lour- 
teen of the cases reviewed. 
Other conditions of less frequency were myositis ossificans, achondro- 
plasia and osteogenesis inperfecta. 
Sadek (15) reports a case of a fourteen year old Egyptian male who 
sustained a laceration of the left thigh with a subsequent cellulitis and 
abscess formation. This was followed by a second abscess in the left arm 
some weeks later. HVhile bedfast from these infections he developed flexion 
contractures of both hips and it was finally necessary to manipulate the 
left hip under anesthesia and apply a hip spica to overcome the contracture. 
The contracture was associated with pain and moderate swelling over the 
left sacroiliac joint and hip. Fifteen days after application of the cast, 
the patient developed frequency, dysuria, cloudy urine and pain in the regioi 
of the bladder. Urinary tract studies revealed a Staph, aureus infection 
and on passing a sound a foreign body of extreme density was encountered in 
the bladder. X-rays revealed a destruction of the left sacroiliac joint. left acetabulum and proximal femur and a pathological dislocation. No 
evidence of any remnant of the head and neck of the femur was noted. There 
was seen a large calcified body in the bladder. 
Through a suprapubic approach the bladder was opened and the head of 
the femur was found in the bladder. The wall of the bladder was intact. 
The patient made an uneventful postoperative recovery. All investigations 
for tuberculosis were negative. The author concludes that the femoral head 
had separated due to septic arthritis, and the same process involving the 
bladder wall allowed the head of the femur to enter the bladder and that 
finally the rent in the bladder healed. 
In a study of the vacuum phenomenon in the hip Joint Jerre (16) states 
that the radiographic visualization of a true ”articular space” is rarely- 
seen. It is recorded in the knee when it is forced into valgus as well as 
in the shoulder when the arm is stretched up and back as far as possible. 
It has also been demonstrated in the metacarpophalangeal joint when traction 
is applied to the finger. In all such cases the area or line of rarefaction 
of the true articular space disappears when the force used is released. The 
experiments of the author lead him to conclude that the forced position pro- 
duced by abducting the tibia on the femur results in a negative pressure 
sufficient to cause a release of gas from the synovia. This gas, however, 
returns to its former state rather quickly after the vacuum is released. 
The rarefaction, which was assumed to indicate the articular space, was 
observed in x-ray study of six cases of epiphyseolysis capitis femoris. 
Some men have indicated that such a phenomenon was characteristic of the 
condition. The author concludes that such an assumption is not Justified, 
The presence of the finding merely indicates that the Joint was simply placed 
in such a position as to create a vacuum at the time the film was taken. 
No pathological significance can be attributed to the finding and it is of 
only theoretical interest. 
In a review of the innervation of the hip Joint as presented in the 
accepted anatomical publications, Kaplan (17) finds that little has been 
added since the earliest of the present day books and the information there 
given is based upon limited dissections. More recently experimental invest- 
igations have been carried out by a number of men in an effort to define 
the method of the production of pain in the hip Joint. Sappey has reported 
that there are no sensory nerves supplying the synovia either in animals or 
man. It has further been determined that the sensibility of the capsule is 
great but quite different from the sensibility of the exterior parts. The 
ligaments were insensible to touch, compression, division and even cauteri- 
zation in the living animal. However, as soon as the Joints were submitted 
to torsion or elongation, the animal showed signs of pain. 
It is obvious that at present, from the viewpoint of anatomy, many 
questions pertaining to the nerve supply of the hip Joint are unanswered. 
The minute details are unknown, the histology of nerve endings is uncertain, 
the physiology of pain is not clear and the part played by the nervous system 
in the production of arthropathies is not entirely explained. It is unknown 
which area of the capsule is supplied by each participating nerve, how they 
overlap and what normal variations of supply occurs in a large number of 
patients. Through the contributions of such men as Garnits, Tavernier and others, 
the procedure of avulsion of the obturator nerve came in vogue as a means of 
relief of the pain in hips of patients -whose debility allowed no extensive 
procedure or in whose case no other treatment was advisable. The obturator 
nerve had for years been known to supply fibers to the joint casule and the 
joint, although the exact mode of the supply and the mechanism of the pro- 
duction of the pain were not known. 
Since 19U5, the author and his colleagues have performed the operation 
on fifty-four patients. The surgery is preceded by a novocain injection 
test to determine the amount of relief from a temporaiy anesthetic of the 
nerve. The technique of the injection is as follows? With the patient 
flat on his back, the leg is abducted to bring out the adductor longus, A 
22 gauge 2 inch needle is introduced near the insertion of -die adductor 
longus close to its lateral border and pushed down to the horizontal ramus 
of the pubis. As soon as the bone is reached the point of the needle is 
deflected down under the horizontal ramus and pushed about 1-1,5 cm, into 
the foramen. Ten cc, of \% novocaine without adrenalin is injected. Relief 
of pain by the injection is considered an indication for the surgical avul- 
sion of the nerve* 
In the surgical avulsion of the nerve, the author utilizes an approach 
through the femoral triangle and the nerve is avulsed at its exit from the 
foramen. He objects to the suprapubic approach of Chandler as more diffi- 
cult particularly in the obese patient* 
The end results in the fifty-four patients operated were? ten patients 
had an excellent early and late results seven had a good result; nineteen 
were improved; seven had no improvement; in eleven cases the information is 
incomplete. Thus, there was a general improvement in about 67%, 
Heilbrun (18) points out that the large number of paraplegic patients 
resulting from World War II serve to emphasize the occurrence of soft tissue 
calcification and erosive bone lesions in the pelvic region of such patients. 
The soft tissue calcifications are most frequent about the hip joint but 
may occur in any muscle or tendon. The most common site of occurrence is 
about the superior border of the greater trochanter. The next most common 
site is in the fascial planes of thighs and buttocks. 
Erosions are noted in the greater trochanters when associated with 
decubiti over the trochanters. There is a loss of configuration of the 
trochanter, and it becomes flattened. Following the healing of the ulcer, 
there is a partial restoration to normal shape of the bone. Three cases are 
presented as illustrations of this condition. 
Pathological Dislocation 
Due to the fact that cartilage undergoes rapid solution in pyogenic 
exudates Bryson (19) states that the condition of suppurative arthritis in 
the infani is an entirely distinct condition from suppurative arthritis at 
any other age. There is a rapid destruction of the cartilaginous head in 
children with pathological dislocation of the hip. In the older age groups the process results in a destruction of the cartilage until there are raw 
bone surfaces opposed and then fusion takes place rather than dislocation. 
The desired objective in the treatment of suppurative arthritis in the 
infant is to obtain a stable, moveable, painless joint with a limb of as 
near normal length as possible. 
The article is based upon a survey of seventeen cases treated by various 
methods including one reconstruction of the Colonna type, four subtrochanteric 
osteotomies, eleven arthrodeses of the hip and one case not as yet surgical- 
ly treated. The follow-up period average? ten years. 
The one case of Colonna arthroplasty was a failure due to redislocation. 
Of those treated by subtrochanteric osteotomy, three of the four were fail- 
ures. The author finds the osteotomy helpful in realigning the limb after 
arthrodesis but a failure when performed primarily. The arthrodesis was by 
far the most successful procedure in reaching the desired criteria as near- 
ly as possible even though motion is sacrificed. Of the eleven cases treated 
by fusion, seven united within a few months and the remainder after a second 
attempt. Failures are thought to be due to the-fact that the patients were 
operated on at too early an age and required a second procedure. 
In the arthrodesis group there was only one case that noticed back pain 
in later life and in this instance the discomfort was trivial. The optimum 
time for arthrodesis is between the ages of twelve and fifteen. 
Traumatic Dislocation 
Stuck (20) states that the circulatory damage resulting from disloca- 
tions of the hip make this injury one of the most crippling. From 30-50$ 
of those sustaining this injury, suffer late symptoms such as pain, limp 
and stiffness. Although the injury has been recorded since the time of 
Hippocrates, it was not until of late years that the extreme importance of 
prolonged and guarded aftercare was appreciated. The precarious blood sup- 
ply to the head of the femur makes dislocation, with its inevitable disrup- 
tion of this supply a major injury. The treatment should be a reduction 
under general anesthesia performed with gentleness. After the reduction of 
a simple dislocation, the patient should be in .bed for two to three weeks 
and then gradually allowed up on crutches. No weight bearing should be per- 
mitted for at least six months. In those dislocations associated with frac- 
ture of the acetabulum, the convalescence will be prolonged for it will be 
necessary to apply post reduction traction in some while in others, surgical 
replacement is required. After the patient begins weight bearing he should 
be followed every two to three months by x-ray examination and at the earliest 
hint of necrosis of the head weight bearing must be discontinued. 
Armstrong (21) reviews 100 cases (101 dislocations) of the hip in the 
light of treatment and end results • The accidents were sustained principal- 
ly in the service during the recent War. 
Regarding the method of sustaining the injury it was found that eight 
were due to wide abduction, ninety-three to a force acting in the long axis 
of the femoral shaft such as sustained in the crash landing of planes with 
the knee forced against the front of the cockpit. Generally it was observed that if the hip joint is flexed and adducted, the force applied in the long 
axis of the femur will produce a simple posterior dislocation through the 
area in which the capsule is relatively weak and the acetabulum is shallow. 
If the flexion and adduction are less there is a resulting dislocation com- 
plicated by fracture of the rim of the acetabulum. If the hip is abducted 
and more or less extended a central fracture dislocation of the acetabulum 
will be produced. 
The following types of dislocations were sustained in the cases surveyed: 
forty-six cases of simple dislocation, forty-three cases of dislocation with 
fracture of the rim of the acetabulum, seven cases of dislocation associated 
with a fracture of the floor of the acetabulum, and five cases of dislocation 
complicated by fracture of the head of the femur. 
In the treatment of simple dislocations, the hip was reduced under gen- 
eral anesthesia and immobilized in a plaster spica for eight weeks. This 
was followed by a period of four weeks of no weight bearing on crutches and 
thereafter the patient was treated at a rehabilitation center four to six 
weeks. Complete recovery was found in 16% of the cases followed. One patient 
was found to have an avascular necrosis of the head of the femur forty-one 
months after injury. 
Of those sustaining dislocation with fracture of the rim of the acetab- 
ulum 65% were judged to have made complete recovery. Nine patients developed 
arthritis and one patient avascular necrosis. In the treatment of these 
cases, the majority required only manipulative reduction to replace the dis- 
location as well as the fragment from the rim of the acetabulum. In those 
in which the fragment remained displaced it was found that the vast majority 
could be replaced by placing the limb in skeletal traction for five or six 
weeks. All were then immobilized in a spica cast for at least eight weeks 
or until the fragment had united. In a few isolated cases, it may be neces- 
sary to resort to open reduction of the fragment. Sciatic nerve paralysis 
occasionally results from the pressure of the displaced fragment and it is 
necessary to speedily reduce the fragment and alleviate the pressure on the 
nerve. 
In the cases of dislocation associated with fracture of the floor of 
the acetabulum, the dislocation can, and was, usually reduced without dif- 
ficulty with traction. However, even then the results are uniformly dis- 
appointing, Of the three central dislocations, two resulted in ankylosis 
and the third in severe and painful arthritis. The four posterior disloca- 
tions with fracture of the floor of the acetabulum all resulted in arthritis 
with pain and loss of motion. The author feels that the treatment of such 
injuries is early arthrodesis of the hip. 
Of the five cases sustaining dislocation with fracture of the head of 
the femur, two obtained good to normal hips and the remaining three had poor 
hips. 
Parker (22) gives a review of the literature regarding traumatic poster- 
ior dislocation of the hip and a discussion of complications and usual assoc- 
iated injuries. The more common complications are fracture of the acetabu- 
lar rim, fracture of the femur, sciatic nerve injury and aseptic necrosis of 
the femoral head. The more widely advocated measures for reduction of 
29o: posterior dislocations of the hip are discussed and the method of simple 
traction by block and pulleys is presented. Two schools of thought are 
generally recognized so far as treatment of such dislocations is concerned: 
(1) Reduction by manipulation for example Bigelow's method; (2) reduction 
by traction and countertraction. The author favors the second group. The 
method presented places the patient on a Hawley table which is locked. The 
peroneal post affords the countertraction element and by using skeletal 
traction forceful pull is applied through the use of pulleys anchored to the 
wall. The method has succeeded in cases in which other means have failed 
and has never failed to afford reduction quickly. It is a useful procedure 
incases of rather long standing posterior dislocation and a case is presented 
in which such dislocation had been present three weeks. 
After considering the results of the usual stereoscopic films of the 
pelvis and both hips in simple dislocation or fracture dislocation of the 
hip, Hunsberger (23) advises an additional view, a direct lateral view of 
the entire pelvis. This may not be possible in severe pelvic fractures but 
in cases in which the patient can be safely positioned on the side, the 
additional view will often give valuable information as to the displacement 
of the femoral head more accurately than can be obtained by the usual 
stereoscopic views. Examination of the patient in bed by the use of a 
portable machine has not proved satisfactory. 
Arthroplasty 
Smith-Petersen (2U) in delivering the Moynihan lecture for the year 
gives a resum£ of the origin and progress in the field of mold arthroplasty. 
The original concept of the approach, now bearing his name, arose from the 
surgical training gained from observing Cushing's neurosurgical technique in 
the cerebellar approach. The approach to the hip, for the first time allows 
adequate exposure so necessary for the proper reconstruction of the joint in 
the use of the mold arthroplasty. 
An opportunity was afforded the author to study a piece of glass removed 
from the back of a patient in 1923, It was found to be surrounded with a 
glistening synovial sac. The idea dawned that such a thing might be applied 
to arthroplasties. In the same year a cup or mold of glass was used in the 
reconstruction of a hip. The result was good until the mold broke. This 
led to further studies and from that time other materials such as viscaloid, 
pyrex, bakelite and finally vitallium were employed in the manufacture of 
the molds. Since the original inception, over 500 hips have been operated 
upon by this method at the Massachusetts General Hospital, These reconstruc- 
tions were performed for such conditions as malum coxae senilis, rheumatoid 
arthritis, complications of fractured hips, congenital dislocations and other 
less common conditions. It is noted that the results in the eases of malum 
coxae senilis were generally quite satisfactory but those obtained in the 
cases of rheumatoid arthritis were only encouraging. However the means cer- 
tainly justified the outcome even when only a small amount of painless mo- 
tion could be obtained in an otherwise solid hip. It has been found necessary 
to revise the first arthroplasty in fifty-three cases for various reasons 
such as errors in early technique, bony proliferation about the cuy, post- 
operative sepsis and for enlargement of the acetabulum. 
Law (25) reviewed a group of 150 vitallium cup arthroplasties. Of the 
150 patients there were 182 hips which had been so reconstructed. There 
were a number of types of pathology for which the procedure had been carried out* More than half the cases were less than two years postoperative. 
In cases of old congenital dislocation of the hip, twelve patients had 
unilateral arthroplasty and four bilateral* The average age at time of 
surgery was thirty-four and a half years. Two postoperative dislocations 
occurred which were corrected by deepening the acetabular socket* One case 
of sepsis will require a future revision* Finally it may be said that of 
the series reported, all but three of the procedures were quite satisfactory. 
This type of case is considered one of the most favorable for arthroplasty. 
Forty-five cases were treated for complications of femoral neck frac- 
ture, Of the group, thirty-five were considered satisfactory and ten un- 
satisfactory. 
Arthroplasty for septic arthritisj There were 2? patients (3U arthro- 
plasties in the group.) Such procedures should be attempted in the late 
stages and well after any evidence of activity has subsided but even then 
there is danger. Four cases were complicated by infection and two cases 
required revision due to bony overgrowth. The range of motion gained in 
these cases is not as satisfactory as in traumatic and noninfective cases. 
Of the group 25 were considered satisfactory and nine unsatisfactory. 
Arthroplasty for rheumatoid arthritis: There were 26 patients (U2 
arthroplasties.) In the final analysis, 33 were considered satisfactory and 
nine unsatisfactory. A total of 13 of the cases required secondary revision 
for bony proliferation or some other reason. Of the entire series the final 
result was less perfect in this condition than in any other. The range of 
motion was decidedly less in this group. It would appear that a fair per- 
centage of them were in the "satisfactory** class but many of those in this 
group which were considered satisfactory would not ordinarily have had such 
a classification. The author calls attention to the fact that some were 
bedridden prior to surgery and now can walk. This in itself, regardless of 
some restriction of motion would make the result seem satisfactory. 
No strict limits are set by the author for his classification of Satis- 
factory" but an estimated value is placed on the result considering the 
original disability and end result. Measurements of motion are made. As 
previously stated, a result may be considered good when appearing in one 
group but poor if the same result was obtained in another i.e. the amount of 
original disability has a profound result on the final classification. 
In summary, the author feels that Q0% of the entire group of 182 arthro- 
plasties are satisfactory. 
Naden (26) reports end results in 36 arthroplasties performed on the 
Orthopaedic Service of the Vancouver General Hospital. On the whole the 
results were gratifying in cases of osteoarthritis of the hip, but very poor 
in rheumatoid arthritis. Twelve patients showed good or fairly good results; 
seven were fair. All four rheumatoid cases were poor. Five patients had 
since died. Nine were gainfully employed in work ranging from brick laying 
and land clearing to short-hand-typing. Five were housewives doing light 
to full housework. Except in the case of rheumatoid arthritis, results were 
better than had been expected and arthroplasty was to be recommended in patient* 
of the older age group, as a procedure of less magnitude than arthrodesis, 
offering good possibility of improvement* Osteotomy 
Fitzgerald (2?) describes a modified Leadbetter osteotomy consisting 
of an anterior approach at the junction of the upper 1/3 with the lower 
2/3 of the neck. The outer fragment of bone is then divided inward as far 
as the fracture line. The new lower fragment is displaced medially and 
with force so that it rotates the head of the femur and comes to lie beneath 
it. This author has utilized the procedure with the following modifications: 
a lateral approach is made using x-ray control. The osteotomy has been 
made at a lower level (junction of lower 1/3 with upper 2/3) to facilitate 
displacement of the shaft and rotation of the head. Six cases have been 
treated by this method with good results. 
A method of subtrochanteric osteotony is presented by Lippman (28) 
with the advantage over the usual type of osteotomy in this region in that 
the danger of slipping is eliminated without the disadvantage of the inser- 
tion of some form of internal fixation. Technique: A lateral approach is 
utilized and a subperiosteal exposure carried out for two to three inches 
below the vastus ridge. The osteotomy commences just at the ridge and 
terminates medially just below the lesser trochanter. The leg is adducted 
and the fragments distracted. A cavity is then curetted in the proximal 
fragment to a depth of one-half to three-quarters of an inch. The obliquely 
cut end of the distal fragment is then shaped into a spike by the use of a 
rongeur. The spike is fitted into the cavity of the proximal fragment and 
the leg abducted to lock it into position. It may be necessary to shorten 
the spike somewhat to obtain the position desired. The desired amount of 
abduction and rotation are secured easily and the leg immobilized by the use 
of a plaster spica. 
Due to the fact that in the abducted position the fragments are im- 
pacted and locked, it has been found possible to remove the spica cast, in 
some cases, at the end of two weeks time, substituting bilateral long leg 
casts connected by a bar to maintain abduction and still allow no danger 
of slipping of the fragments. 
Aseptic Necrosis 
Jackson and Bickel (29) report an unusual case of aseptic necrosis of 
the head of the femur Tollowing a minor fracture of the greater trochanter, 
A sixty-four year old male sustained a fall on his knees and then rolled 
onto the left side. At the time of the injuiy he experienced some pain in 
the knees and the left hip but was soon able to arise and walk seven blocks 
to his place of employment. The pain became more severe with the passage of 
time and he was seen because of severe pain in the left hip. Examination 
revealed a fracture of the greater trochanter with little displacement of 
the fragment. He was treated by rest in bed and made an uneventful recovery. 
He was discharged from the hospital thirty-two days after admission with 
instructions to remain on his crutches. These were eventually discarded, and 
the patient noticed no discomfort. He was seen on numerous occasions in the 
following weeks with the x-rays finally showing healing of the fracture. He 
was again seen twenty-four months after the injury and at that time roent- 
genographic examination revealed a typical aseptic necrosis of the head of 
the femur. He was treated by no weight bearing on crutches. The follow-up 
was terminated with the sudden death of the patient from a ruptured aneurysm 
of the abdominal aorta. The authors review the accepted anatomical facts regarding the blood 
supply to the femoral head and concur that the principal source is through 
the capsular vessels and the vessels in the ligamentum teres. The etiology 
of this patient’s trouble cannot be determined unless there was a thrombus 
in the vessels supplying the hip- There was no fracture to produce the 
interruption of the blood supply. 
Chandler (30) states that infarction of the head of the femur in the 
clinical sense is a group of symptoms, dominated by pain, loss of function 
and bony collapse caused by deficiency in arterial nutrition of the head 
of the femur prolonged enough to result in marked degeneration or even ne- 
crosis of bone. The condition occurs two or three times as commonly in men 
as in women and usually between fifty and seventy years of age. 
A clear comparison is possible between the heart and the femoral head. 
The heart lies in the pericardial sac much as the head of the femur lies 
in the synovial lined capsule of the hip joint. The blood supply is similar, 
in that the vessels are really end arteries in each case and similar in 
their gross anatomical configuration. Impairment of circulation, due to 
vascular obstruction from any cause, is followed by degenerative changes in 
either myocardium or bone. The degree of degeneration and the effectiveness 
of repair depends upon the extent of the vascular impairment and establish- 
ment of an adequate collateral circulation. 
In the head of the femur, because of its bony composition, degenerative 
changes are delayed in their appearance either grossly or on x-ray. Like- 
wise repair is a slow process and accomplished through what Phemister describes 
as ’’creeping substitution.” 
The terms coxae malum senilis and aseptic necrosis merely describe the 
condition at a given time but convey no meaning nor understanding of the fore- 
going basic pathology. It is the author's hope that a more widespread and 
clear understanding of the concept of "coronary disease of the hip” will 
throw more light on our knowledge of many pathological processes of the hip 
joint. 
An attempt is made by Badgley and Denham (31) to first limit the ter- 
minology now in use regarding ’’aseptic necrosis” and "avascular necrosis”. 
True, much confusion exists in the literature so that for the purposes of 
this article the terms are given their boundaries. Avascular necrosis is 
defined as death to part or all of the head of the femur due to vascular 
damage primarily of the posterior and anterior circumflex femoral arteries. 
Aseptic necrosis is used to denote a process of repair, a dynamic time per- 
iod in which the death of a part of the head is incomplete. It involves 
the potential collapse of the remaining untransformed portion of the head or 
the possible development of a degenerative arthritis. It is a descriptive 
term for the cartilage changes, necrosis and the loss of joint space. 
It is found that U0$ of the cases of fracture of the neck of the femur 
which are treated by internal fixation and in which bony union is successful 
are followed by the development of avascular necrosis* The authors are in 
agreement with Watson-Jones that internal fixation itself has no bearing 
upon the development of avascular necrosis in these fractures* In the treatment and prevention of avascular necrosis, care must be 
taken to avoid further injury to the blood supply of a hip already frac- 
tured, Rough handling in transport may further damage the vascular sup- 
ply, No forceful manipulation should be employed in the reduction of the 
fractures. It is felt that the treatment should be instituted as early as 
possible and that a delay of two weeks certainly leads to a poorer prognosis 
than in the case nailed at once. Open reduction should be avoided if at 
all possible for this can only damage the already precarious blood supply 
to the head. No weight bearing should be permitted for at least six months. 
Avascular necrosis of the head of the femur may lead to 1, complete 
reformation of the head to a vital functioning structure, 2. aseptic necro- 
sis, 3, degenerative arthritis, or U, nonunion. 
Arthrodesis 
Simmonds (32) reports a case of a twenty year old white male who devel- 
oped osteomyelitis of the pelvis at the age of twelve. This was followed 
by fusion of both hips. The left hip fused in ten degrees adduction, neu- 
tral rotation and twenty degrees flexion. The right hip fused at twenty 
degrees abduction, forty degrees external rotation and fifty degrees flexion. 
Fith hips fused in these positions, the boy can easily walk five miles, dance 
as well as run up and down stairs. There is no discomfort. In view of this 
case the author raises the question as to whether one is justified in fusing 
hips in the customary almost full extension and whether it might not be 
advisable to flex one hip twenty degrees and the other forty to fifty degrees 
for purposes of ankylosis. 
Langston (33) has utilized the Brittain method of arthrodesis of the 
hip in 28 cases and from these, draws certain conclusions, presents a few 
cautions and describes three modifications of technique which he feels 
facilitates the procedure. 
Regarding the principles of the procedure: (1) It allows a true extra- 
articular method of arthrodesis away from the disease process in the hip, 
(2) Deformities can be corrected at the time of surgery and this may elimi- 
nate the necessity for a second operation. (3) The removal of the pull of 
the adductors will frequently in itself result in improvement in the patho- 
logical process in the hip joint, (U) The minimum, age considered advisable 
for the procedure is ten years. 
A few of the more important disadvantages are (1) The constant danger 
of damage to the sciatic nerve, (2) The fixation of the graft in the ischium 
is necessarily blind and at times fails to make contact or may fail to be 
firnnly fixed in the previously made cut in the ischium, (3) Cases are known 
in which a misdirected graft not only damaged the sciatic nerve but in one 
instance perforated the external iliac artery, (U) In the five failures in 
this series, all were the result of failure to properly place the graft in 
the ischium. 
The insertion of a guide wire under x-ray control prior to beginning 
the osteotomy is considered advantageous. Also the femoral osteotomy must 
be a clean cut and care taken to avoid leaving a spike on the inner cortex 
of the femur which will prevent proper medial displacement of the shaft. Brittain (3U) outlines in detail the operation of ischio-femoral 
arthrodesis which he described first in 19hl. It is admitted that this form 
of arthrodesis is not feasible in all hips because the diseased process oc- 
casionally involves the ischium. 
The technique is as follows: With the patient on an orthopedic table 
two skin clips are placed over the head of the femur. A calibrated guide 
is inserted on the anteroinferior aspect of the shaft and neck of the femur. 
An x-ray is made. While this is being developed a tibial bone graft is cut. 
It is preferable to take the graft from the affected limb in order that the 
sound limb may have full strength for convalescence. It is essential to cut 
a wide tibial graft* The whole basis of the ischio-femoral arthrodesis is 
the use of a wide tibial graft, which is more certain to engage the ischium. 
The graft should include the posterolateral and posteromedial borders of the 
tibia. Beginning one inch above the greater trochanter a curved incision is 
made, with the convexity upwards, and is carried four inches below the tro- 
chanter. The shaft of the femur is exposed, A site for the osteotony is 
chosen, bearing in mind that the lower limit of the greater trochanter is a 
point which is easy to verify, and that the skin clips are an additional 
guide. A small hand drill is introduced through the femur at an angle of 
forty-five degrees in the coronal plane. After the inner wall of the femur 
has been pierced, there is a lack of resistance until the ischium is struck. 
An x-ray is then made to verify the position of the drill, A subtrochanteric 
osteotomy is performed. Special chisels are used with screws to separate 
them; one chisel with a slot and shoulders receives the other. After the 
osteotomy has been performed by one chisel (the male) it is tapped inwards 
until it engages the ischium. An x-ray is then taken for position and the 
other chisel is then introduced below the first* The chisels are separated 
widely by means of the screw provided and thus a V-shaped slot is made in 
the ischium. The male chisel is then withdrawn. The graft is tapped along 
the remaining chisel. As the graft is tapped, the chisel is withdrawn-. When 
the graft is felt to engage the ischium, it is tapped solidly home. The 
distal fragment of the femur is then displaced medially Until it makes con- 
tact with the ischium, thereby supporting the middle of the graft. 
The author has performed the operation 105 times on ninety-five patients 
with eighty-two successful fusions. These procedures have been carried out 
for tuberculosis of the hip, osteoarthritis and infective arthritis. 
Of the important complications, striking the sciatic nerve is prominent. 
It is felt that if the chisel is kept in the horizontal plane and the hip 
is not flexed this danger is not great. Hemorrhage is to be guarded against. 
This most often can result from misdirection of the graft on the chisel and 
damage to the obturator artery or branches of the lateral femoral circumflex 
artery* 
The reasons given for failures are: (1) passing the chisel or the graft 
through the obturator foramen, (2) nonunion between the osteotomized fragments 
or between the graft and the femoral fragment at the outer end and (3) exten- 
sion of the disease into the area of the graft. 
At the time of writing, L. Mayer (35) states that no cases of injury to 
the sciatic nerve during the Brittain operation have appeared in the litera- 
ture although they are known to have occurred. Due to the close proximity of the sciatic nerve, cases are sure to occur* The author presents a case of 
a woman suffering from tuberculosis of tne hip. - A Brittain type fusion was 
carried out as usual with no operative or immediate postoperative difficulties 
However as soon as the patient regained consciousness, there was noted com- 
plete loss of sciatic nerve function in the foot. The lower portion of the 
cast was removed to eliminate the possibility of pressure on the peroneal 
nerve but such was not the causative factor. After neurosurgical consulta- 
tion, an exploration of the sciatic nerve was carried out. As soon as tne 
sciatic nerve was exposed there was a sudden gush of dark blood from a large 
hematoma which completely surrounded the nerve and infiltrated it. The 
nerve was freed and at no place was it found to have sustained direct injury. 
The tibial graft had passed \ inch from the nerve and it was the bleeding of 
the soft tissues incident to this placing of the graft that had produced 
the hematoma. The nerve was transplanted. The patient made a gradual recov- 
ery and obtained good fusion of the hip although at the time of writing she 
still had not regained all sciatic nerve power and was wearing a brace. It 
is of interest further to note that nine months following surgery the patient 
apparently with little or no trauma suffered a fractured tibia at the site 
from which the graft had been taken. Furthermore, Mayer estimates that 50 
to 70$ of the cases operated at the hospital have incurred such a fracture. 
The author favors the mechanics of the Brittain operation but feels 
the posterior approach as utilized by Trumble and at the Massachusetts Gener- 
al Hospital should replace the "blind” insertion of the graft. In addition, 
such an approach would allow the use of iliac grafts or smaller tibial grafts 
and eliminate the complication of tibial fracture. 
Karlen (36) reviews cases of arthrodesis of the hip by nailing process 
performed between 1936-19U6. There was a total of 95 operations; five pa- 
tients had a second operation. Mortality rate of the group was 5.3$. The 
first eighteen fusions utilized the regular three flanged nail driven well 
across into the acetabulum. Of this group, eight showed slipping of the 
nail. However, final analysis showed three of the eight had solid union and 
one had a fibrous ankylosis with good clinical result. The simple three 
flanged nail was then replaced by a fenestrated nail. Also the simple extra- 
articular arthrodesis gave way to a transarticular arthrodesis combined with 
intra-articular arthrodesis. A total of forty cases had fixation with tne 
fenestrated nail. Twenty-seven of these had simple transarticular nailing 
and thirteen the combined procedure. Although the use of a fenestrated nail 
eliminated the complication of slipping, twelve nails broke at one of the 
fenestrations. Four of the twelve went on to bony ankylosis. The postopera- 
tive period was merely bed rest and no fixation by plaster, a fact accounting 
for a major part if not all fractured nails. 
The author’s statistics reveal a rather high incidence of fibrous 
union in those cases treated by simple transarticular nailing without intra- 
articular arthrodesis (20 of U3 cases). In the same group there were eight 
cases with no union, When the intra-articular procedure was added, a mucn 
better result was noted (16 bony ankylosis in 21 cases). The author contends 
that mere x-ray evidence of fibrous union is not a particularly condemning 
item since ti2% had clinical ankylosis and a good result when all cases are 
considered as a group. Irrespective of nail type or use of intra-articular 
procedure the results show 50.6$ bony ankylosis, 31.5$ fibrous union, 11.2$ 
non-union and 5.7$ deaths. This type of arthrodesis has the distinct advantage of reducing the 
postoperative period of recumbency. The average period was only 3.2 weeks 
in the simple transarticular nailing (fibrous union high) and 9.9 weeks in 
the combined type of procedure* 
Developmental Coxa Vara 
LeMesurier (37) discusses developmental coxa vara, based upon fifteen 
cases seen at Children‘s Hospital, Toronto, During the same length of time 
one hundred ninety-seven congenital dislocations of the hip were seen. 
This illustrates the relative infrequency of this condition, A case in an 
adult is also included. There was a familial tendency noted as four of 
the patients were related* 
Usually the limp or waddle appeared at three or four years of age, after 
preceding normal ambulation* There was no relation to injury. Late second- 
ary arthritic changes brought the adult case to seek treatment at the age of 
forty* Examination quite uniformly reveals limitation of motion at the hip 
primarily in abduction. There was marked uniformity of x-ray findings charac- 
terized by a triangular bony defect distal to the capital epiphysis, on the 
inferior border of the femoral neck, associated with a variable degree of 
coxa vara. The author feels that these x-ray findings are in themselves di- 
agnostic, There were bone changes seen distal to this defective region. 
These were essentially those of variation in bone density of an extreme de- 
gree resembling fragmentation. The author believes that the defect is car- 
tilage which has incompletely ossified and the bending of the neck occurs 
from this structural weakness. 
Attempts at correction of the coxa vara by traction were unsuccessful. 
Abduction osteotomy between or below the trochanters gave satisfactory re- 
sults in twelve hips with improvement of the weight-bearing mechanics and 
healing of the neck defect within a year. All osteotomies healed without 
incident. Three cases seen early and before coxa vara deformity was pro- 
nounced were treated by cortical grafting through the neck into the epiphysis 
through a drill hole placed from the lateral femoral surface. These three 
cases showed evidence of healing of the femoral neck defect three to four 
months postoperatively, without coxa vara occurring or progressing. One case 
treated by closed nailing with a Smith-Petersen nail failed to show healing 
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Clin,, North America, 28: 1025-1030, Aug. 19h8 
30. Chandler, F. A,: Coronary disease of hip, J. Internal, Coll. Surg,, 
11: 3U-36, Jan.-Feb. 19U8 31. Badgley, C. E. and Denham, R, H.s Aseptic necrosis of femoral head 
following fracture of hip, J, A, M. A.-, 137: 1193-11%, July 19R8 
32. Simmonds, F. A,: Bilateral bony ankylosis of hip Joints, Proc. Roy. 
Soc. Med., Ul: 3d6, June 19U8 
33. Langston, H. H,: Brittain method of arthrodesis of hip, Proc. Roy. 
Soc. Med., UO: 895-898, Dec. 19^7 
3U. Brittain, H. A.: Ischio-femoral arthrodesis, J, Bone and Joint Surg., 
30B; 6U2-650, Nov. 19U8 
35* Mayer, L.: Critique of Brittain operation for fusion of hip, Bull, 
Hosp, Joint Dis,, New lork, 9: U-8, April 19U8 
36. Karlen, A,: On complications following nailing arthrodesis of hip 
Joint, Acta. Orthop, Scandinav,, 17: 195-21U, 19U8 
37# LeMesurier, A, B.: Developmental coxa vara, J. Bone and Joint Surg., 
30B: 595-605, Nov, 19U8 SECTION lh 
CONDITIONS INVOLVING THE KNEE JOINT 
Prepared by Milton S. Thompson, Colonel, M. C., U, S. A, 
and Resident Staff 
!• Arthrography - Meschan and McGaw (1) compare the arthrographic 
and operative findings in 3l£ knees which were operated upon from 19k2 to 
19h5* They found their results 81,6$ accurate and of particular value in 
diagnosis of abnormalities of the menisci, fat pads, and bursae. They 
have found the procedure to be without risk and use it in all cases of sus- 
pected internal derangement of the knee. 
Colonna (2) describes the differential diagnosis of intra-articular 
lesions of the knee joint, specifically traumatic arthritis, hypertrophied 
fat pads, intermittent hydrops, internal derangements, loose bodies, syno- 
vial tumors, tuberculosis, and Charcot joints. He discusses the etiology 
and the treatment of these conditions. 
2. Anatomy - Gardner (3) studied the nerve supply to the human knee 
joint by making serial sections and reconstructions of fetal joints and by 
dissecting adult joints. He has considered the femoral nerve, the tibial 
nerve, the common peroneal nerve, and the obturator nerve. There are Ik 
articular branches from these four nerves and he has traced them to the 
portion of the joint that they innervate. The only specificity that he 
has demonstrated is that the branches of the femoral nerve supply the Su- 
prapatellar recess and the patellar periosteum and that those of the com- 
mon peroneal nerves supply the tibial tuberosity. All other areas he de- 
scribed are supplied by the articular filament of at least two of these 
large nerves. He notes a concentration of fibers in the posterior capsule, 
suggesting that it may be a center of proprioception. (Ed. Note: This 
study appears to be of little clinical value because of the lack of speci- 
ficity of innervation of these articular branches. For example, articular 
filaments of all four of these large nerves supply the infrapatellar fat 
pad. The concentration of fibers in the posterior capsule, which he de- 
scribes, is presumably not the subsartorial plexus). 
Last (ii) reviews the anatomy of the knee joint capsule and accessory 
ligaments, the intra-articular structures, the movements of the knee, and 
the muscle attachments near the knee joint. He reminds us that the medial 
ligament is not a ribbon, but a broad, flat triangle, which extends posteri- 
orly along the joint line and down the tibia the breadth of a hand. He de- 
scribes how the fetal capsule perforates when the infant walks and there- 
after communicates with the suprapatellar bursa. He describes the cruciate 
ligaments as being "wound up” by lateral rotation of the flexed tibia and 
"unwound” by medial rotation. He explains how the popliteus muscle pulls 
the lateral cartilage back out of harm's way when the flexed tibia is rotated laterally by the hamstrings. He shows that the last part of full 
extension of the knee is lateral rotation of the tibia, because the shorter 
lateral femoral condyle is "used up" first; and how flexion movement is be- 
gun by the popliteus by medially rotating the tibia, thus being the antag- 
onist of the lower fibers of the vastus lateralis. There are six drawings 
to illustrate this article, 
Helfet (5>) gives his conception of the function of the cruciate liga- 
ments'! rfe feels that they act as guide ropes, rather than check ropes. 
The anterior cruciate pulls the tibia into lateral rotation on terminal 
extension, which is necessary for stabilization in this position. Bucket- 
handle tears of the medial meniscus block lateral rotation and result in 
limitation of extension until the ligaments are stretched so that full ex- 
tension is obtained without lateral rotation. The author transplants the 
patellar tendon medially for anterior cruciate weakness which increases 
lateral rotation of the tibia in flexion. The posterior cruciate ligament 
rotates the tibia medially when the knee is flexed. Surgical treatment of 
relaxation of this structure consists of transplanting the semitendinosus 
tendon into a groove on the medial femoral condyle, which, he states, in- 
creases the medial rotation of the tibia in flexion. He reports five cases 
of surgically treated cruciate weaknesses, in which the abnormal movement 
was still present at rest, but which had increased knee stability in walk- 
ing. This he attributes to a return toward normal tibial rotation, 
3. Deformities - Smillie (6) describes the anatomical and pathologi- 
cal features of 29 congenital discoid menisci which he encountered in his 
personal series of 1300 meniscectomies. He classifies these 29 cases and 
compares them with those of the cases previously recorded in literature. 
He found one case of medial discoid cartilage and compared it with the 
only other case known to be recorded. He recognizes three anatomical types 
of discoid cartilages and describes them as follows: 
a. Primitive types (15 cases) This type shows early cessation of 
any intention of becoming a meniscus. It has a thick medial border, 
b. Intermediate type: (8 cases) It is less massive, has a thin 
central zone and a thin medial border, 
c. Infantile type: (6 cases) It is more like the normal structure, 
but has a broader central portion. 
He gives the characteristic lesions of each type in detail. 
Hamilton (7) feels that the non-rachitic cases of genu valgum are due 
to lack of* muscle tone and that stretch of the internal lateral ligament 
is secondary. He urges that children with poor muscle tone be taught early 
to use their muscles, even at three months of age. If the condition is 
present at 15 to 18 months he uses an elevation on the medial side of the 
heel in addition to the exercises, 
Wagner (8) writes of seven cases of fixed extension of the knee, vary- 
ing in age from 2k to U7, Four followed open operations of femur fractures; one was due to GO arthritis; and two due to synovectomy following synovitis. 
He describes his method of capsulotoray and quadriceps lengthening and em- 
phasized physiotherapy and reconditioning. His best results took two years 
to obtain. 
U. Infections - Gordon and Shechter (9) report a case of salmonella 
suipestifer (hog cholera bacillus) infection of the knee joint and review 
the literature reporting these Infections in humans. The patient was a 38 
year old negro male who showed clinical improvement on the third day of 
streptomycin therapy and made a complete recovery in three months, 
Harris and Meyers (10) tell of a case of the same infection in the 
knee joint of a soldier in Italy, 20 days after a compound fracture of the 
midshaft of the tibia and fibula. Sulfadiazine and penicillin with arthro- 
toray resulted in recovery. The end result was not known. 
5. Cysts and Ganglia - Moore (11) reviews three cases with popliteal 
varices t^it pre-operatively were"diagnosed as Baker's cysts. All three 
cases responded well to surgical excision. The author could find reports 
of only two other cases of popliteal varices in the literature. 
Levine (12) describes the third case of ganglion of the anterior cru- 
ciate ligament in the literature. His case was associated with osteochon- 
dritis of the patella and he discusses theories of pathogenesis of this 
ganglion. He states that his is the first case reported in the English lit- 
erature • 
6. Injuries, Prevention of - Quigley (13) recommends measures to re- 
duce knee injuries in football players. Those players with history of pre- 
vious knee injuries, operations, or instability are strapped with adhesive 
before each practice session and game. The "Duke-Simpson" strapping is 
used and its application is described. 
?• Injuries, Fractures - Cave (1U) discusses the mechanism of frac- 
tures of the tibia! condyles and the associated injuries to the ligaments 
and menisci. He feels that fractures with little displacement and severe 
fractures of both condyles are best treated by closed manipulation and 
traction. Depressed fractures of one condyle are treated by open reduction. 
He describes the procedure in which fragments are replaced and held with a 
long bolt. Repair of torn cruciates and collateral ligaments is not carried 
out. If fragments are able to be fixed well, early exercises are started 
in a hinged brace with weight bearing in two to six months. 
8. Injuries, Internal Derangements - McMurray (lf>) reviews the ana- 
tomy of the knee joint, the symptoms of internal derangement, the conserva- 
tive and operative treatment, and the differential diagnosis. He stresses 
conservative treatment of all ligamentous injuries, with immobilization in 
V-> to 20 degrees of flexion for two to three months, 
Lipscomb and Henderson (16) present a study of 66U arthrotomies for 
internal derangement done at the Mayo Clinic. The diagnostic triad of 
locking, pain, and swelling was present in 70 per cent of the cases. As- 
sociated lesions of the ligaments or of the patella give poor prognosis. 
These authors believe that surgeons not greatly skilled in meniscectomies 
should remove only the anterior or torn segments, and that if the whole 
meniscus is removed, it should be done through two incisions. They view with skepticism the diagnoses of hypertrophic fat pad and fibriliated or 
loose cartilage as the cause of symptoms* 
Peabody and Walsh (1?) discuss at length the diagnosis of knee Joint 
derangement illustrating with typical cases. They believe chondropathy of 
the patella has a higher incidence than any other internal derangement* 
They restate their belief that patellectomies should be done in some cases 
of traumatic chondritis of the patella, in severe traumatic types, and in 
the presenescent type, but that resurfacing of the patella is the treatment 
of choice in the chondromalacia type and in younger persons. They describe 
an approach for meniscectomy which they believe gives greater exposure with 
less trauma* A parapatellar incision is continued down to the Joint line 
where it curves medially to the anterior fibers of the collateral ligament 
"a few inches below the Joint line*” The capsule flap including synovia is 
dissected subperiosteally and retracted medially. The meniscus is removed 
from before backwards as usual. 
10. Injuries, Late Changes - Norley and Coventry (18) add 12 cases 
of calcification of the meniscus to their previous nine. Two types are 
described — the primary type with calcium throughout, starting at the 
periphery, are usually multiple and probably due to nutritional and de- 
generative changes. The secondary type show local deposits, involve a 
younger group of patients and are due to trauma. Most symptoms were of 
long duration. Three received surgical treatment and complete cure while 
the remainder improved on heat, rest, massage, and elastic support. Cal- 
cium was found in all three surgically treated, but there was no ossifica- 
tion. 
Ghormley (19) discusses results to be expected as late changes in 
Joints which are the site of internal derangements of various sorts. Many 
of these may be minimized or prevented by early removal of loose bodies, 
torn cartilages, and other damaging structures. In other cases, synovec- 
tomy may be necessary to relieve th6 condition. In many cases, however, 
much can be done to prevent the damaging development by advising the pa- 
tient of his condition, by showing him how to develop muscular stability 
of the Joint by means of exercises,and by teaching him to avoid the more 
strenuous activities. Patients should also be taught to avoid excess 
weight, a very important factor in many cases. 
Fairbank (20) made an investigation of changes in the knee Joint from 
three months to 1U years after meniscectomy and found three types of 
changes, excluding osteoarthritis. They are; 
a. Ridge formation on the femoral condyle; b. Narrowing of the 
Joint spacej c. Flattening of femoral condyle. 
Operation 
Total Cases 
No Change 
Ridge 
Narrowing 
Flattening 
Medial 
Meniscectomy 
80 
33* 
h3% 
32* 
18* 
Lateral 
Meniscectomy 
27 
50* 
1% 
UO* 
17* (Narrowing plus flattening were the commonest changes found in combination) 
The author suggests that these changes result from the loss of the 
weight bearing function of the meniscus and describes an ingenious mech- 
anical proof of this function* He contends that meniscectomy is not fully 
innocuous, but is unable to establish a connection with later osteoarthri- 
tis definite enough to Justify clinical deductions. 
Haldeman and Soto-Hall (21) discuss the importance of the articular 
cartilage in knee Joint lesions* The etiology of chondromalacia and osteo- 
chondritis dissecans is reviewed* The early surgical correction of lesions 
involving articular cartilage is stressed. 
11* Surgery, Meniscectomy - Charnley (22) in considering the causes 
of unsatisfactory results of meniscectomies during war time, suspected 
vertical and oblique scars as being the source of slow recovery and post- 
operative effusion from ’’scar friction’1. One scar, markedly nodular, was 
removed and found to cause a click on the bony ridge between the articular 
and non-articular surfaces of the femur* On the synovial surface of this 
scar was an irregular white line which was hard and gritty, and without mu- 
cous cells. In view of these findings he operated on 103 knees through 
the horizontal incision used for many years by Platt* Operative technique 
is described as a two inch horizontal incision at the level of the head 
of the tibia from the patellar ligament to the collateral ligament, through 
skin and capsule* The synovia is opened along the superior border of the 
meniscus which is then removed in the usual manner. End result of 103 
soldiers showed 76% perfect or much improved, 16\% a little better or the 
same and percent worse. It was the author’s impression that the imme- 
diate recovery was quicker and less eventful with the horizontal incision. 
Early arthritis, ulceration of the articular cartilage and ligamentous in- 
stability were recognized at operation in 23 cases with the same per dent 
of successful results. Total and sub-total removals analyzed separately 
showed no material difference in the results. (Ed. Note; No reference 
was made to the time elapsed between operation and evaluation). 
12. Surgery, Arthrodesis - Charnley (23) reports cases of arthro- 
desis of toe knee joint by the use of a positive pressure method which he 
believes is superior to any other* Clinical union was obtained in from 12 
days to 6 weeks after operation. Under force of compression a cellular 
response is stimulated in the osteoblasts* Although fixation is important 
he believes compression is the main factor* The technique of the method 
is described* The theoretical conception of how bone union occurs under 
compression is given with illustrations. The technique comprises the in- 
sertion of Steinmann pins transversely through the femur and tibia and 
connecting them with a longitudinal bolt on each side so that they can be 
approximated with wing nuts. The pins are arrang0d to lie on a Thomas 
splint for immobilization. 
13* Surgery, Arthroplasty - Samson (2U) reported late results in h3 
arthroplasties ox the knee joint followed for more than five years. The 
cases include gonococcal arthritis, 10} traumatic arthritis, 2; osteomye- 
litis, 1; and tuberculosis, 1. The indication for arthroplasty was an- 
kylosis of both knees or of the hip and knee joints on the same side. Only active resistive exercises were used and when necessary manipulation 
under anesthesia. Pain was not complained of and only one unstable knee 
due to absorption of the medial femoral condyle was reported. All had 
full active extension with flexion from 20 degrees to 90 degrees or more. 
Re-ankylosis occurred in 12 cases. 
Mayer (2£) reports a case of arthroplasty of the knee done on a pa- 
tient with rheumatoid arthritis in whom the opposite knee had previously 
been fused, A satisfactory arthroplasty was produced without the use of 
metal or of soft tissue flaps interposed between the bone ends. It was 
thought that the good result was due, in part at least, to continuous 
traction for three months post-operatively, combined with daily assisted 
active motion started 10 days post-operatively. 
III.. Surgery, Patellectomy - Gray (26) discusses the incidence, anat- 
omy, radiological examination,and clinical features of chondromalacia of 
the patella. He recommends excision of the patella, as he feels that it 
is impossible to restore the smoothness of the articular cartilage. He 
reports seven cases who had excellent results following patellectomy. 
Coleman (2?) reviews the merits of excision of the patella. In his 
series of 32 cases the results were excellent in 23, good in 6, fair in 2, 
and poor in 1. He considers that early motion, with intensive quadriceps 
resistance exercises are important. A frequent complaint was aching in 
the knee, after long sitting, which was relieved by straightening the joint. 
McFarland (28) advocated excision of the patella as the operation of 
choice for recurrent dislocation. The immediate result is excellent and 
late osteoarthritis is avoided, A typical case is presented with color 
photographs showing the pathological changes in the cartilage of the pa- 
tella and the femoral condyle at operation. 
1$• Surgery, Synovectomy - Pardee (29) reviews the literature re- 
lating to synovectomy of the knee joint and lists the following patholo- 
gical conditions as benefited by synovectomy: 
a. Chronic infections; b. Traumatic arthritis; c. Hypertrophic 
arthritis; d. Osteochondromatosis; e. Benign tumors; f. Intermittent 
hydrarthrosis; g. Villous arthritis; h. Pigmented villonodular synovitis. 
He considers tuberculous synovitis a contraindication for synovectomy. 
A general statement expressing the opinion of the majority of the authors 
as to the indications for synovectomy could not be made. Pain is probably 
the paramount indication. The author presents a series of U0 patients 
operated upon. Eight had bilateral synovectomy and all requested the sec- 
ond operation because of the relief obtained from the first synovectomy. 
The end result after one, two, and five years are shown in a chart. The 
immediate excellent result is often misleading. The end result in terns 
of relief of pain and increase of function are universally good in cases 
of traumatic arthritis, chondromatosis and benign tumors with the poorest 
results in polyarticular rheumatoid or hypertrophic arthritis. 
Paparella-Treccia (30) agrees with Wittraoser that the meniscus of the 
knee contains two histological elements, chondroid and tendinous, in the relation of two to one. After the embryological development has been 
concluded there is no blood supply to the chondroid tissue. The tendin- 
ous portion receives some blood supply from the capsular arteries. The 
author studied photomicrographs of the menisci in 8 cases of poliomyeli- 
tis, He found that: 
(1) the menisci had lost the differentiation between tendinous and 
chondroid portions. 
(2) there was an increase in blood supply to the structures adjoining 
the menisci. 
(3) there was vascular invasion along the convex margin of the menisci 
and also at the concavity. 
(U) there was appreciable histological evidence of blood vessel pro- 
liferation with the greatest vascular invasion in the cases with the most 
severe nerve involvement. BIBLIOGRAPHY 
1. Meschan, I* and McGaw, ¥. H.: New methods of pneumoarthrography 
of knee with evaluation of procedure in 315 operated cases. Radio- 
logy, 1*9: 675-711, Dec. 191*7 
2. Colonna, P. C.r Diagnosis of lesions in knee joint. Bull. Chicago 
M. Soc., 51: 173-176, Sept, 1*, 19l*8 
3. Gardner, E.s The innervation of knee joint, Anat. Rec., 101s 109-130, 
May 19U8 
1*. Last, R, J.s Some anatomical details of knee joint, J. Bone and Joint 
Surg., 30B; 683-688, Nov. 191*8 
5. Helfet, A. J.: Function of cruciate ligaments of knee joint, Lancet, 
Is*665-667, May 191*8 
6. Smillie, I, S.s Congenital discoid meniscus, J. Bone and Joint Surg., 
30Bs 671-682, Nov. 191*8 
7. Hamilton, A. s Genu valgum, Brit. M. J., 2: 533, Sept. 1*, 191*8 
8. Wagner, L. C.t Fixed extension of knee due to capsular contraction. 
New York State J. Med., 1*8: 19l*-198, Jan. 15, 191*8 
9. Gordon, E. J. and Schechter, *N.s Salmonella suipestifer pyarthrosis 
of knee joint, J. Bone and Joint Surg., 30A: 220-221*, Jan. 191*8 
10. Harris, H. W. and Meyers, S. G.j Salmonella suipestifer infection of 
knee joint, J. Bone and Joint Surg., 30A: 217-219, Jan. 191*8 
11. Moore, M., Jr.s Popliteal varices simulating Baker1s cyst. South. 
Surg., U*s 1, Jan. 191*8 
12. Levine, J.s Ganglion of anterior cruciate ligament. Surgery, 21*: 
836-81*0, Nov. 191*8 
13. Quigley, T. B.: Management of knee injuries incurred in college foot- 
ball, Surg., Gynec., and Obst., 87: 569-575, Nov. 191*8 
ll*. Cave, E. F.; Fractures of tibial condyles involving knee joint, Surg., 
Gynec. and Obst., 86; 289-291*, Mar. 191*8 
15. McMurray, T. P.: Internal derangements of knee joint, Ann. Roy. Col. 
Surg., Eng., 3: 210-219, Oct. 191*8 16* Lipscomb, P. R. and Henderson, M. S.: Internal derangements of 
knee, J. A. M. A., 13$: 827-831, Nov. 191+7 
17. Peabody, C, V/. and Walsh, F. P.: Surgery of knee joint derangements, 
Surg. Clin. North America, 28: 12U7-127!?, Oct. 191$ 
18. Norley, T. and Coventry, M. B. s Calcification of menisci of knee, 
Proc. Staff Meet. Mayo Clin., 23: 281-287, May 19k& 
19. Ghormley, R. K.: Late joint changes as result of internal derange- 
ments of knee. Am. J. Surg., 76: 1+96-501, Nov. 191+8 
20. Fairbank, T. J.: Knee joint changes after meniscectomy, J. Bone and 
Joint Surg., 30B: 661+-670, Nov. 191+8 
21. Halderaan, K. 0. and Soto-Hall, R.: Response of articular cartilage 
to trauma with special reference to knee joint, California M. J., 
69; 179-182, Sept. 191+8 
22. Chamley, J.: Horizontal approach to medial semilunar cartilage, 
J. Bone and Joint Surg., 30B: 659-663, Nov. 191+8 
23* Charnley, J.: Positive pressure in arthrodesis of knee joint, J. 
Bone and Joint Surg., 30B; 1+87-1+86, Aug. 191+8 
2l+. Samson, J. E.: Late results in arthroplasty of knee, J. Bone and 
Joint Surg., 30B: 220, Feb. 191+8 
25. Mayer, J. H.: Arthroplasty of knee, Proc. Roy. Soc. Med., Lond., 
1+1: 570, Sept. 191+3 
26. Gray, C.: Chondromalacia patellae, Brit. M. J., 1: 1+27-1+30, Mar. 6, 
19148 
27. Coleman, H. M.: Excision of patella, J. Bone and Joint Surg., 30B: 
221, Feb. 191+8 
28. McFarland, B.: Excision of patella for recurrent dislocation, J. Bone 
and Joint Surg., 303: 158-160, Feb. 191+8 
29* Pardee, M. L.: Synovectomy of knee joint., J. Bone and Joint Surg., 
30A: 908-911+, Oct. 191+8 
30. Paparella-Treccia* Sulla Isto-Patologia Dei Manischi Articolari Del 
Ginocchio Negle Esiti Di Poliomielite Anteriore Acuta, Ortop. Traumat. 
App. Mo tore, 15: 1, 37-1+7, Jan-Mar. 191+8 
3io SECTION 
CONDITIONS INVOLVING THE FOOT AND ANKLE 
Prepared by Ernest A. 3rav, Colonel, M. C., U. S. A. 
Anatomy 
Lapidus (1) contends that man is the only primate that has fully 
adopted the upright plantigrade stride and that only man has a longitu- 
dinal arch. He believes that the foot is a rigid frame created to pro- 
vide strength in response to the new functional requirements of the up- 
right plantigrade stride. The integrity of the arch in standing is main- 
tained mainly by passive support of the ligaments, the muscles playing a 
secondary part. The theoretical shock absorbing function of the arch com- 
pared with the semi-elliptical spring of a carriage is not acceptable since 
the plantar fascia and ligaments are not elastic. 
Kaplan (2) points out that retraction on the common peroneal nerve in 
operations near the upper end of the fibula often results in weakness or 
paralysis of the extensor longus hallucis muscle. The muscular branches 
of the deep peroneal nerve (anterior tibial) vary in size and length. The 
nerve to the extensor longus hallucis is frequently found in cadavers to 
be the longest and thinnest of these branches. Forceful retraction upward 
and posteriorly on the deep peroneal nerve in these cadavers produced a 
tear of the nerve to the extensor longus hallucis muscle. If the retrac- 
tion was made forward and upward, nerve damage did not occur. Therefore, 
in operative procedures near the head of the fibula, it is advisable to 
place the knee in slight flexion and gently retract the nerve over the 
fibular head upward and forward. 
Mechanical Abnormalities 
Harris and Beath (3) report their observations in the study of the 
feet of 3600 recruits in the Canadian Army. They divide flat foot into 
3 types: a* hyperraobile flat foot with short tendo Achillis, b. peroneal 
spastic flat foot, and c. simple depression of the longitudinal arch. 
Hypermobile flat foot with short tendo Achillis is based on a congenital 
anomaly of the structure of the talus and os calcfs, so the deformity ap- 
pears early in life. There is a strong hereditary tendency. The typical 
flatness is present only on weight bearing and normal shape is resumed 
when weight bearing is removed. It can usually be corrected by voluntary 
effort on the part of the patient. The range of dorsiflexion of the ankle 
is greatly limited due to the short tendo Achillis, There is also an un- 
due laxity, instability and hypsmobility at the subtalar and raidtarsal 
joints. The forepart of the foot is swung out and there is external ro- 
tation in relation to the leg. The calcaneus is in valgus and the head 
of the talus is thrust forward and downward. The incidence of the severe 
type of hypermobile flat foot was one in every 11*5 men examined. In the 3619 soldiers examined, there were 25 cases of severe and 192 
cases of mild hypermobile flat foot* Examination of the foot bones of 
200 cadavers in the Dept, of Anatomy at the University of Toronto revealed 
marked variation in the mechanical sufficiency of the talo-calcaneal articu- 
lation which would appear to be the basis for the instability of this joint* 
The authors made x-ray studies of the feet of the 3619 soldiers and found 
a close parallel between weak support of the talus as evidenced on the 
films and the presence of hypermobile flat foot with short tendo Achillis* 
The basic factor is bony instability but the support of ligaments and muscles 
is a modifying contribution. In the strong foot little load is thrown on 
the muscles. In the average foot the complementary contributions from the 
skeleton and muscles provide satisfactory stability. In the weak foot, 
the load thrown upon the muscles is unduly great. Treatment consists of 
shoe modifications to assist the weakened skeletal support and exercises 
to improve muscle power. In the severe cases which do not benefit by con- 
servative means, the authors recommend fusion of the talo-navicular and 
talo-calcaneal joints with implantation of cancellous bone grafts. Late 
adolescence or early adult life is the optimum time for such a procedure. 
They estimate that 10$ of such cases are suitable for operative treatment. 
Harris and Death (i;) find it difficult to believe that the condition 
known as peroneal" spastic flat foot develops from a flexible flat foot by 
reason of the stresses which fall upon the tarsal joints. Flexible flat 
foot is common in childhood and not accompanied by spasm. Spastic flat 
foot is rare, usually dates back to childhood and there is the history 
that the foot was always stiff. Furthermore, procaine block, nerve sec- 
tion and even tendon section are often followed by a persistence of the 
deformity and rigidity. Of 3600 Canadian males examined for enlistment, 
7l| had peroneal spastic flat foot (2$). In nearly all cases the lateral 
films showed lipping of the superior margin of the head of the talus. 
At operation two years previously on a case of peroneal spastic flat 
foot the authors noted a bridge of bone springing from the medial surface 
of the talus and continuing to the medial surface of the calcaneus. Since 
then they have noted this abnormality in 12 of 1? additional cases. Of 
the remaining 5* three had bony bars between the calcaneus and navicular 
and two had tarsal rheumatoid arthritis. X-ray visualization of both the 
calcaneo-navicular bar and the talo-calcaneal bridge is accomplished by a 
postero-anterior projection thru the heel at the downward angle of i*5 de- 
grees, the leg shadows being separated by flexing the knees. The authors 
believe that most cases of so-called peroneal spastic flat foot are due 
to these two congenital anomalies, that the apparent spasm is really only 
an adaptive peroneal shortening and that these cases are rigid rather than 
spastic. There is a smaller group of patients with rheumatic conditions 
of the feet in which true peroneal spasm is a secondary feature. The 
authors recommend subtalar and talonavicular arthrodesis in the rigid 
cases when disability is severe. In cases with severe deformity the 
peroneal tendons may be lengthened. Operation is not done until adolescence 
in any case. In childhood repeated manipulation and the use of Whitman 
plates are the methods of choice. 
Apley (5) reports a case of a five year old boy with weakness of the 
legs and a tendency for the feet to give way into a position of marked 
valgus with collapse of the long arches when he attempts to stand. There is the history of a dermoid cyst having been removed shortly after birth 
from the upper dorsal region followed by moderate hydrocephalus and re- 
tarded physical and mental development. There was a bilateral extensor 
Babinski reflex. The author attributes the inability to stand in spite 
of the presence of leg muscles to the underlying neurologic condition with 
failure to acquire a normal postural reflex. Since the muscles are unable 
to balance the body on the feet, the longitudinal arch collapses. The au- 
thor postulates that lack of myelinization of the pyramidal tract may in- 
hibit the development of the postural reflex. 
Baker (6) states that an examination of the feet of 3000 young women 
during World 'War II revealed that in kl% there was the need of some treat- 
ment for a foot disorder and that, of these, 2%% actually required treat- 
ment before they could be employed in the Auxiliary Territorial Service. 
The condition which caused most pain and loss of working hours was the 
postural valgus or unbalanced foot. A very small percentage had structural 
changes. Since the war the author has been working with school children 
and prescribing postural foot exercises designed to mobilize all essential 
joints, to strengthen muscles and to induce relaxation. 
Fitzgerald (7) points out that a high arch may more frequently give 
rise tot trouble than a low one. Support of the long arches of the feet is 
dependent upon the bony structure and the ligamentous attachments, with 
considerable aid from the muscular structures. These cases are divided 
into four groups: (1) postural flat foot, usually in adolescence and due 
to muscular weakness, (2) equinus flat foot secondary to short tendo Achillis, 
(3) flat foot due to metatarsus varus, and (U) rigid flat foot. The stan- 
dard methods of treatment are briefly described. 
Tucker (8) reviews briefly the anatomy of the foot and the etiology 
and treatment of postural or static flat foot, the flat foot of early 
childhood, spastic flat foot and Morton's metatarsalgia. 
Nissen (9) states that the neuralgic pain felt in the sole of the foot 
in the region of the 3rd and l±th toes, with onset on standing or walking 
and relief by removal of the shoe, was described by T. G. Morton in 1867. 
Betts in 19i;0 described a fibrous swelling of the plantar digital nerve 
as the pathologic finding, with complete relief by resection of the nerve. 
The author studied 27 cases of plantar neuralgia. Only one patient had 
definite swelling in the digital cleft and diminished sensation was only 
an occasional finding. The condition was bilateral in 8 cases. Thirty- 
five operations were performed by longitudinal incisions between the com- 
mon flexor sheaths. Usually the nerve is sought where it crosses the 
transverse ligament. The whole nerve and vascular bundle are excised. 
The author has had no difficulty with the scar from weight bearing and 
pain disappears within a few days. Histologic examination revealed de- 
generation of the digital artery with fibrosis of the digital nerve. The 
nerve changes are thought to be ischemic in origin. 
Winkler, Feltner and Kimrnelstiel (10) review a series of 20 patients 
with pain and tingling in the region of the 3rd and i±th toes and tenderness 
and a sensation of a nodule in the web between these toes. Relief was obtained by operation, A dorsal incision was used and the thickened 
enlargement of the plantar digital nerve was resected. There were no 
trophic complications. Pathological changes in the nerves consisted of 
massive thickening together with fibrosis and myelinization of the per- 
ineurium, The authors attribute these changes to a degenerative pro- 
cess subsequent to trauma. 
Jones (11) states that hallux valgus may reveal itself in early 
adolescence and occurs in these cases almost invariably in females. Ab- 
duction of the great toe and permanent bunion may occur as early as 12 
years of age. It is due to congenital or developmental adduction of the 
first metatarsal bone possibly on an atavistic basis. Secondary changes 
and deformity may be due to shoe pressure. Lesser deformities can be im- 
proved by stretching, exercises and night splinting. In more severe cases 
simple excision of the exostosis without interference with the epiphysis 
at the base of the phalanx or resection of the head of the metatarsal may 
be adequate. Usually however, a wedge shaped osteotomy thru the proximal 
portion of the shaft of the metatarsal is indicated. Only a portion of 
the wedge is removed and the remainder is fixed into the proximal medullary 
canal for stabilization. Six weeks immobilization in a leg; and foot plaster 
is required postoperatively. Good results are usually obtained but the 
operation is only done when there is persistent pain from shoe pressure. 
After operation the subluxation of the phalanx is automatically relieved. 
The procedure is entirely extra-articular. 
In the etiology of painful heels. Wood (12) considers periostitis, 
exostoses, fractures, epiphysitis, retrocalcaneal or plantar calcaneal 
bursitis, the ’’neuralgic heel”, strain of the plantar fascia, and various 
skin lesions. The treatment of each condition is briefly discussed. 
Pridie (13) reports the development of a mass-produced molded rubber 
heel £or the correction of unbalanced and pronated feet. The rubber heel 
is elongated along the medial border, has a flange to support the region 
of the longitudinal arch and has the added effect of a l/8n inside wedge. 
The device has the advantage of flexibility and ease of application with 
avoidance of rigid fixation of the foot. The ordinary heel is removed 
by the retailer who stocks tne molded curator heel and the supportive, 
properly fitted rubber heel is applied in its place. 
Traumatic Disturbances 
Gibson and MacKinnon (1U) present four cases of subtalar dislocation 
of the foot with minor fractures. In spite of the admittedly precarious 
blood supply to the talus there was no aseptic necrosis in their cases 
nor has it been reported in the cases described in the literature on this 
subject. All authors emphasize the relative ease of closed reduction by 
plantar flexion and abduction. Secondary operative procedures for trau- 
matic arthritis are not usually required. 
Bell (l£) reports a case of medial and posterior dislocation of the 
foot bhru the subastragalar joint without evidence of fracture. The in- 
jury was due to severe adduction and plantar flexion of the foot in a baseball accident. Reduction was accomplished by manipulation under an- 
esthesia with further plantar flexion of the foot and forceful abduction. 
The treatment consisted of immobilization in a non-padded plaster for six 
weeks with weight bearing at the end of 10 days. Early return of motion 
was noted on removal of the plaster. The late result is unknown. 
Newcomb and Brav (16) report the rare instance of a complete disloca- 
tion of the talus from its normal articulations. There was apparently a 
90 degree rotation of the bone thru both vertical and horizontal axes. 
The position of the bone was transverse to the horizontal axis of the foot 
and its posterior portion was lateral and anterior to the fibula. There 
was no fracture. Reduction was accomplished by Kirschner wire traction 
thru the calcaneus with counter-traction on a Steinmann pin thru the tibia. 
Pressure in a postero-medial direction over the lateral prominence of the 
talus accomplished the reduction. The wire and pin were removed after ro- 
entgenograms revealed restoration of normal anatomy. Four weeks immobili- 
zation was carried out. Roentgenograms at the end of six months revealed 
no evidence of aseptic necrosis in spite of the marked disruption of cap- 
sular attachments and obvious circulatory embarrassment which were present 
at the time of injury. The major nutrient supply to the talus is thru the 
dense superior talonavicular ligament. Some remaining strands of this liga- 
ment may have been the basis for revascularization of the totally displaced 
talus. 
Goldstein (17) points out that in severe sprains of the ankle, injury 
to the lateral ligaments must be suspected. Negative routine x-ray exam- 
ination does not rule out serious injury. In rupture of the ligaments 
there is usually the history of a snap at the time of injury and an egg 
shaped swelling occurs below the lateral malleolus. Tenderness over the 
distal tibio-fibular joint is a constant finding. Forty-one such ankles 
were subjected to inversion stress under anesthesia and 29 of these showed 
30 degrees or more tilt of the talus. Seven showed less than 30 degrees 
tilt and 5 showed no tilt. The uninjured ankle was always similarly tested. 
Occasionally as much as 10 degrees tilt has been noted in normal ankles. 
The author treats the cases with significant tilt by short leg plasters in 
the neutral position for a period of eight weeks. He concludes that cor- 
rect diagnosis and adequate treatment will prevent the symptoms of an un- 
stable ankle. Of 101 acute ankle sprains seen in an Array General Hospital, 
28$ were found to have complete rupture of the lateral ligament. The im- 
portance of examination in inversion and adequate immobilization to prevent 
permanent disability is stressed. 
Kestler (18) emphasizes that early and accurate diagnosis of minimal 
as well as extensive trauma to the ligamentous structures of the ankle 
joint will insure the possibility of a good end result. He recommends 
that every inversion injury of the ankle be subjected to special x-ray 
examination accomplished under 2% procaine anesthesia produced by injection 
into the sinus tarsi, lJM anterior to the tip of the lateral malleolus. 
An A-P view is then taken with the forefoot held in extreme inversion. In 
a series of 15 normal ankles so anesthetized and examined, no degree of 
tilt of the talus was noted. The authors had eleven traumatic cases which 
revealed a tilt of the talus on this examination. Five were noted shortly after injury and were treated by plaster fixation for 8-12 weeks. Of the 
chronic cases, three were mild enough to be improved by similar conserva- 
tive treatment, but three required operative repair. 
At the Annual Meeting of the Canadian Orthopaedic Association, Pennal 
(19) presented an anatomic and clinical study of injury to the anterior and 
middle fasciculi of the external lateral ligament of the ankle with tilting 
of the talus on roentgenographic examination of the inverted foot. The im- 
portance of adequate treatment in the acute cases to prevent chronic weak- 
ness and recurrent dislocation was stressed. In the refractive types treat- 
ment by tenodesis of the peroneus brevis muscle resulted in stable painless 
ankles with full range of joint motion. 
Leonard (20) studied £l inversion injuries of the ankle. Twenty-three 
were shown to be spontaneously induced subluxations by roentgen examinations 
under local or general anesthesia. Experimentally, a study of seven preserved 
ankles in which all soft parts except the collateral ligaments had been re- 
moved, suggested that the ligament most commonly injured was the anterior 
talo-fibular and this is the usual area of the local tenderness clinically. 
V/hen the foot is in equinus, after cutting the anterior talo-fibular liga- 
ments, there is less stability than when the foot is at a right angle. In- 
version films should therefore be made in equinus. 
Pearson, Adams and Denny-Brown (21) report the case of a twenty four year 
old mle who complained of severe pain in both legs shortly after engaging 
in broad jumping on a cement sidewalk. There was the development in twenty- 
four hours of a moderate fever, with swelling and tenderness of the pre- 
tibial muscles and bilateral paralysis of the anterior tibial, extensor 
digitorura and extensor longus hallucis muscles. Albuminuria developed 
within a few days. The pain and tenderness gradually subsided but paralysis 
continued. Muscle biopsy on the l?th day revealed hemorrhage, extensive 
muscle necrosis and proliferation of fibrous tissue. The systemic reaction 
gradually subsided but five months later the paralysis was still present. 
The authors believe that absence of reflex changes or sensory loss and the 
lack of electrical excitability of the involved muscles excluded a peri- 
pheral nerve lesion. There was no evidence either clinical or pathological 
of an injury to the anterior tibial artery. It is concluded that violent 
muscular exertion caused partial rupture of the muscle fibers and the at- 
tendant hemorrhage and swelling produced ischemia and necrosis. 
Bonnin (22) discusses the common bone injuries to the foot and ankle 
and divides the ankle fractures into traction and compression injuries. 
The latter may occur alone but are more commonly combined with external 
rotation, abduction or adduction forces. The treatment of each variety 
is discussed. In the case of fractures of the os calcis, the author con- 
siders only two types - the first, in which the subtalar joint is damaged 
and the second, in which it is not. He states that this is the determining 
factor in the prognosis and not the change in the so-called salient angle. 
Maneuvers to restore the shape of the bone require considerable force and 
a long period of immobilization which adversely affect the end result. It 
has been shown that it is more profitable to exercise the foot and ankle 
from the beginning. Elevation is used until swelling subsides. Generally the foot is too painful for weight bearing until 6-8 weeks but massage 
and exercises are utilized almost at once. By this regime, patients 
get on their feet more quickly, the incidence of post-fracture pain is 
diminished and, while cases of subastragalar arthritis demanding eventual 
arthrodesis will not be completely avoided, fewer will be encountered. 
Starr (23) discusses tibio-fibular diastasis and its treatment by 
screw tixa t ion with or without denuding the tibio-fibular joint. Chronic 
sprain of the lateral ankle ligaments may be associated with osteochon- 
dritis dissecans of the astragalus and often requires operative repair 
and reinforcement by a transplant of peroneus tendon. Ankle, metatarsal, 
os calcis and astragalus fractures are briefly discussed. 
Developmental Abnormalities 
Zadek and Gold (2h) found eight children with accessory tarsal scaphoids, 
six being bilateral. These 16 feet were x-rayed at intervals to determine 
the fate of this accessory element located medially and posteriorly to the 
tubercle of the tarsal scaphoid bone. Definite fusion occurred in 5 instances, 
partial in 3 and failure of fusion in 6. The authors made sections of ex- 
cised accessory scaphoid bones and their continuous scaphoid surfaces. In 
no case itfas there a true joint surface present. Ordinarily there was a 
layer of soft tissue consisting of hyaline cartilage, fibro-cartilage or a 
mixture of the two. No synovial-lined joint capsule was encountered. There 
were varying degrees of ossification of the cartilaginous plate. The authors 
noted evidence of trauma in the specimens in the form of hemorrhages, or- 
ganizing fibrous tissue and callus-like reparative tissue. It is possible 
that these accessory scaphoids may be painful due to stress from the pos- 
terior tibial tendon as a result of mechanical foot weakness. Other trau- 
mata must also be considered in the etiology of the discomfort. 
Hughes (25) observed a series of x-rays of the heels of 23 children 
complaining of painful heels compared with x-rays of painless heels thru 
the age period between 6 and li* years. Altho most writers have attributed 
these painful heels to osteochondrosis of the epiphysis of the os calcis 
and have compared the condition with Osgood-Schlatter1s disease, the author 
could find no roentgenologic appearance in the painful group to distinguish 
it from the asymptomatic varieties. Both groups showed cases of irregularity, 
flattening, fluffiness and fragmentation of the epiphysis. The epiphyseal 
line was often clouded and in some areas obliterated*. It is concluded 
that since there is no histologic evidence of a diseased epiphysis in 
these painful heels and since the roentgenologic appearance is similar to 
that seen in painless heels, there is no proof that osteochondrosis or 
epiphysitis is the underlying cause of the patients1 complaints. 
Skin Conditions 
Russell (26) decries the use of radiation therapy in the treatment 
of plantar warts and advises repeated formalin soaks followed by removal 
with scissors, or a combination of curettage and electric cauterization. 
Hanby (27) believes that the chiropodist can take care of most cases of 
plantar warts in 3 or i* visits and there is no scarring or temporary dis- 
ability. A few resistant cases may come to the surgeon. Kurtin and Yontef (28) feel that the treatment of plantar warts con- 
sists in trimming until a cavity is produced. The foot is then held hori- 
zontal and a drop of 25$ suspension of resin of podophyllum in liquid pet- 
rolatum is placed into the cavity. The surrounding skin is painted for a 
distance of with collodion. A 2" strip of well flamed adhesive tape is 
then placed directly over the lesion. The patient resumes activity and 
the adhesive may be reinforced but it is not replaced for eight days. The 
base of the wart then appears as a grayish substance which can be scooped 
out. The podophyllum is then re-applied and the treatment repeated. After 
the third or fourth treatment a clean painless cavity is seen. Tissue re- 
action is minimal. The cavity heals rapidly and in a few days healthy tis- 
sue reaches the surface. The authors postulate that the success of their 
treatment depends on the creation of a constant macerated state of the tis- 
sue by the adhesive. This produces the medium which is present in genital 
warts where podophyllum treatment has been found so efficacious. The re- 
sults of this technique in a small series of plantar warts has been very 
satisfactory. 
Watkins (29) reviews 150 cases of plantar warts in children. The lar- 
gest percentage (66$) occurred between the ages of 11 and 15 with only 7$ 
between 5 and 7 years. The majority had only one wart, but 23 cases had 
multiple warts, 80$ occurred on the plantar metatarsal area and 20$ on 
the heels. The treatment was by means of excision of callus and the ap- 
plication of chlorosal (60$ salicylic acid and 5$ chloral hydrate) covered 
with adhesive. Treatments were repeated in 7 to li* days. An average of 
three treatments was required. There were no recurrences. 
McLaughlin (30) states that radiotherapy of plantar warts often pro- 
duce cause severe disability entirely disproportionate to 
such a simple condition. The author recommends simple treatment under lo- 
cal anesthesia by excision of callus and thorough reaming out of the wart 
with a curette. The base is then touched with a diathermy needle or an 
electric cautery to prevent recurrence. This produces a saucerization of 
the area, A plug of gauze is inserted for 1*8 hours but the patient starts 
weight bearing immediately. Healing is usually complete in 7-10 days. 
Tobias (31) classifies plantar warts as (1) the solitary common variety, 
(2) multiple (65$ of cases), (3) infective, (1*) mother-daughter type, and 
(5) mosaic warts which occur in map-like arrangement and are not painful. 
Warts usually appear over pressure points. The author has never seen a 
case in a Negro. 'Sie incidence is greater in women. Epidemics of warts 
among school children have occurred, indicating some infectious element. 
The exciting cause is thought to be an epitheliotropic virus. The author 
recommends radiation treatment with an average dose of 2100 r. in 3 frac- 
tionated Joses. No roentgen sequelae occurred in these cases. There were 
only 9.6$ failures by this method. It is stated that radiation necrosis 
may occur from overdosage, frequent small doses, careless records or fail- 
ure to shield the wart to the very edge of the lesion. No patient should 
be treated who has received previous x-ray therapy until the exact pre- 
vious dosage is known. 
Shaw (32) states that in some cases of plantar warts treated by ra- 
diation, chronic intractable ulceration of the sole resulted in disability out of all proportion to the importance of the original lesion. Recurrence 
follows simple excision of the ulcers and deep fibrosis leads to an un- 
stable tender scar which prevents normal walking. Free skin grafts are 
unlikely to provide permanent cover. The author reports two cases treated 
by direct pedicle flaps from the opposite leg. The ulcer was excised and 
the flap raised and partially attached. Three to four weeks later the flap 
was separated and completely attached to the site of ulceration. Healing 
occurred rapidly in both cases and walking was comfortably accomplished 
about two months after the initial procedure. 
Operative Procedures 
To overcome the objection of a formidable operative procedure and the 
cosmetic result of a thick ugly ankle which often attends arthrodesis by 
complete elimination of articular surfaces, Gallle (33) has devised a sim- 
pler procedure which is equally effective. Two vertical incisions in front 
of the malleoli expose the ankle Joint. Deep mortises ij11 long, wide 
and 1” deep are cut across the Joint surface on either side. Thru a third 
incision in front of the leg, a cortical graft 3M long and 1” wide is cut 
from the tibia. This is divided in two, and each half is hammered solidly 
into the mortises in front of the ankle. When this has been accomplished 
no motion is present and the skin can be closed without fear of displace- 
ment. The proper degree of equinus must be produced before the mortises 
are cut. The author has used the method in 2$ cases. Four months of 
plaster immobilization is required. The procedure produces no shortening 
and no ankle thickening, it can be done in a short period of time and the 
grafts are placed so that there is minimal strain when weight bearing is 
begun. 
Adams (3U) describes his technique of ankle arthrodesis which con- 
sists of a transfibular approach and the use of the lower kn of the fibula 
as an onlay graft after removal of its medial cortex. The cartilage is 
removed from the talus and the tibia thru the lateral incision and can- 
cellous chips are used for dead spaces. The fibula is then fastened 
across the Joint laterally by three screws. Weight bearing is encouraged 
in a few weeks but plaster fixation is used for a minimum of 12 weeks. A 
series of 30 cases is reported with primary success in 28, but two patients 
required secondary procedures. 
In cases of £th hammer toes which do not respond to conservative treat- 
ment by metatarsal pads and sole wedges, Michele and Kreuger (3!?) recommend 
a subperiosteal resection of tie entire proximal phalanx. The capsular 
attachments are separated carefully from the proximal and distal ends of 
the phalanx and these structures are sutured following removal of the bone* 
The patient is ambulatory in one week and results have been satisfactory 
from the functional and cosmetic viewpoints in 61 cases. 
Sallick and Blum (36) report that in severe crush fractures of the 
heel and, in some cases, in spite of minimal anatomical distmtbance fol- 
lowing careful reduction, patients have been left with disablingly pain- 
ful feet. Conversely, some severely crushed bones give relatively pain- 
less feet. Correction of skeletal deformity is not the only objective. Relief of pain might be an important physiologic approach to the problem 
regardless of the bone changes, so denervation of the heel occurred to 
the authors as a possible solution. This has been used extensively in 
the treatment of pain in peripheral vascular disease. The tibial and 
sural nerves are responsible for sensation of the heel. These nerves are 
chiefly sensory at the ankle but in the case of the tibial nerve there is 
a motor element to some of the small plantar muscles. Division of the 
nerve results in no significant loss of function but, since sensory loss 
to the sole of the foot would be produced, the medial calcaneal branch of 
this nerve is the portion which is attacked. The approach is thru two 
short vertical incisions posteriorly, just above the ankle. The authors 
report seven cases all of whom had persistent pain for 1 year following 
heel fractures before denervation was done. They were followed four 
months to five years after nerve section. Four patients have returned 
to work but in three the disability has persisted. Gases must be care- 
fully selected, must have had adequate conservative treatment and display 
a desire to get well. There was little choice between resection or simple 
division and resuture. No trophic sequelae occurred in this group of pa- 
tients • 
At the meeting of the Canadian Orthopedic Association, Frenette (37) 
reviewed a series of 756 cases of infantile paralysis treated by tendon 
transfer, astragalectomy, arthrodesis and bone block. The results of ten- 
don transfer alone were good in 67$. When used in conjunction with sta- 
bilization procedures there were good results in 86$. Astragalectomy re- 
sulted in painless stable mobile feet in 76$. Arthrodeses of various types 
were satisfactory in percentages ranging between 80$ in the case of triple 
arthrodesis with or without bone block and 92$ in the cases of panarthro- 
desis for stabilization of the foot in equinus, either-to compensate for 
shortening or to permit locking of a flail knee in hyperextension. 
Schnute (38) and his associates have performed 26 foot stabilizations 
of theLambrinudi type with uniformly good results. The preoperative 
planning of the wedge to be removed, the location of the notch in the in- 
ferior surface of the scaphoid and the maintenance of the normal astragalo- 
calcaneal relationship to avoid a varus foot are technical details to be 
carefully considered. 
Ficai (39) states that no case of dislocation of the foot without 
fracture of the malleoli has been reported and many authors have denied 
the existence of such a lesion on theoretical reasons. He describes the 
case of a 25 year old soldier who fell from a truck and sustained a sim- 
ple posterior dislocation of the ankle without fracture. Upon examination 
the patient was unable to move his foot. X-rays revealed a small chip 
from the internal malleolus. No other bone pathology was found. The dis- 
location was reduced under general anesthesia and maintained in plaster 
for 10 days. The patient returned to normal function 20 days after re- 
moval of the plaster. The author presumes that the patient had pre-existing 
relaxation of the ligaments and feels that otherwise the injury would have 
included a fractured malleolus or at least a tibio-fibular separation. 
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39. Ficai, A.: Su Di Un Caso Di Lussazione Posteriore Del Piede Senza 
Lesioni Dei Tegumenti, Ortop, Traumat. App. Motors, 15: 27-30, Jan-Mar. SECTION 16 
CONDITIONS INVOLVING THE SHOULDER AND NECK 
Prepared by Roy C. Rounds, Lt. Col,, M, C,, U. S, A. F, 
Anatomy 
Nauta and Landsmeer (1) review the anatomy of the periarticular tis- 
sues of the shoulder joint. Their study includes the observations of other 
anatomists, in particular Rouvier’s and Frohse Frankel’s text books, and 
the special papers of Henke, Pfuhl and Kahlmeter as well as their own per- 
sonal observations. A description of the subacrominal bursa is especially 
well presented. The authors agree with Pfuhl that there is sufficient rea- 
son to regard this bursa as a true joint, although an exceptional one func- 
tionally and morphologically. The belief is founded on the following facts; 
(1) the argument of Pfuhl that the portion of musculo-tendinous cuff formed 
by the supraspinatus tendon and the coracohumeral ligament can be regarded 
as an intra-articular disc, (2) it is the only bursa known to be able to 
reduce friction between two skeletal elements (the greater tuberosity of 
the humerus and the acromion), and (3), it has a mechanism, through its 
attachment to the subdeltoid fascia, which keeps it extended during move- 
ment in a manner similar to the mechanism about two joints which prevents 
intra-articular incarceration of capsular folds. Functionally, therefore, 
the bursa acts to reduce the conflict arising between the shoulder joint, 
which is an exceptionally mobile structure, and the rigid tissues surround- 
ing it. Morphologically, it differs from true joints in that it is largely 
a synovial sac with only a minor portion of its wall composed of cartilage. 
In a comprehensive, well illustrated report on the nerve supply of 
thershoulder joint, Gardner (2) adds to our present knowledge of the in- 
nervation of this region. Modern texts of anatomy describe in varying de- 
tail its innervation by the subscapular, axillary, suprascapular and an- 
terior thoracic nerves. His study is based on the dissection of 7 adult 
shoulder joints and serial sections of U fetal shoulders. Four additional 
adult shoulders were partially dissected to confirm points brought out in 
the fetal shoulder studies. In addition to confirming the major features 
of existing descriptions, Gardner was able to demonstrate nerve branches 
not previously described. In two fetal specimens small twigs arose from 
the radial nerve, ascended in the adventitia of the brachial artery to the 
origin of the anterior circumflex humeral artery where they appeared to 
anastomose with the bicipital branch of the axillary nerve. In the same 
specimens another twig of the radial nerve, ascending the long head of the 
triceps brachii, was traced just up to the capsule of the joint where it 
disappeared. An articular branch of the posterior cord of the brachial 
plexus was initially discovered in the fetal specimens and later confirmed 
in dissections. It supplies fibers to the anterior region of the capsule 
and synovia, also supplied by the branches of the suprascapular and anterior 
thoracic nerves. Fetal sections also focused attention to articular 
branches of the lateral anterior thoracic nerve. These branches accompany a branqh of the thoraco-acromial artery and after crossing the coracoid 
process reach the acromioclavicular joint and send a twig to the antero- 
superior region of the shoulder joint capsule. Sympathetic fibers were 
traced in two fetal specimens from their origin in the stellate ganglion 
in one specimen, and the sympathetic trunk just superior to this ganglion 
in the other, to the shoulder joint. Fibers of similar origin found in 
the other two specimens could not be followed beyond their entrance into 
the adventitia of the axillary artery. In addition to this previously 
undescribed innervation of the shoulder joint the author traces in detail 
the courses of the articular branches of the axillary, anteriorthoracic 
and suprascapular nerves. 
Krahl (3) believes that the spiral course of the bicipital groove is 
visible evidence that torsion has occurred in the proximal diaphyseo- 
epiphyseal joint. In the adult humerus the bicipital groove describes a 
gentle spiral course from lateral to medial as it descends, and the angle 
through which it turns bears a fixed relationship to the torsion angle. 
This angle slowly increases with age up to the 20th year, and the degree 
of torsion is in direct proportion to the force of muscles which rotate the 
humerus• 
Recurrent Dislocation of the Shoulder 
Palmer and Widen (U) believe that the essential lesion contributing 
to subluxation, a term they feel more descriptive than dislocation, is 
the deformity of the humeral head. In a study, based on 60 operations, 
this lesion, described as a typical compression fracture in the posterior 
part of the head was constant, as demonstrated by radiograph, arthrograph, 
and at operation. The labrum showed varying degrees of injury in 56 cases, 
but in h instances no abnormality of this structure could be demonstrated. 
They use a bone block in the repair of all their cases, a technique first 
described by Hybbinette and Eden, and briefly present the operative steps 
in this procedure. In a follow-up study varying from 1-1/2 to 12 years, 
there was recurrence of dislocation in k of their cases (6.7 percent). Re- 
currence in each instance followed severe trauma. 
Hark (5) found lesions of the glenoid labrum and capsule in each of 
i|0 shoulders operated for recurrent dislocations. Seventy five percent of 
his cases were former soldiers, and the glenoid disruption in this group 
was more extensive than in the civilian group. In those cases where there 
is erosion or separation of the glenoid lip, he uses a bone peg graft ob- 
tained from the coracoid process to deepen the anterior glenoid rim. 
In a series of 17 consecutive cases of recurrent dislocation of the 
shoulder joint Eyre-Brook (6) found detachment of the glenoid labrum plus 
a groove on the posterior surface of the head of the humerus in 8 cases, 
detachment of glenoid labrum and capsule alone in 5 cases, groove on the 
posterior surface of the humeral head alone in 3 cases, and one case with 
detachment of the subscapularis muscle from its insertion. 
Adams (7) reviews 180 cases of recurrent dislocation of the shoulder 
occurring in members of the Royal Air Force. One hundred and fifty nine operations were performed to correct this disability. At surgery, exam- 
ination of the glenoid labrum disclosed detachment of the labrum as de- 
scribed by Bankart and others in 8? percent of 79 cases examined. When 
detached, some degree of stripping of the anterior capsule from the sca- 
pular neck was invariably present. Adequate radiographic exam nation of 
the humeral head in 68 cases shewed well defined bone defects to be pre- 
sent in (82 percent). In all of the cases without labrum detachment 
(13 percent), a defect in the humeral head was present. It is his be- 
lief, on the basis of these findings, that the major causative factor per- 
mitting redislocation is the glenoid labrum detachment and capsular strip- 
ping from the anterior scapular neck. But, dislocation may result without 
the presence of this pathology, and is due to the defect in the head of 
the humerus. Five mechanisms producing the original dislocation are dis- 
cussed; (1) Fall on the abducted arm. (2) Direct blow from behind, acting 
on the head of the humerus. (3) Hyperextension of the abducted arm. (i|) 
Excessive external rotation in abduction. (5) Inferior dislocation follow- 
ing hyperabduction of arm. The Nicola procedure was done on 59 cases with 
36 percent recurrence, the Bankart on 18 cases with one recurrence, and 
the Putti-Platt on 37 cases with two recurrences. Although, following the 
Nicola procedure, less limitation of external rotation of the shoulder re- 
sults, the author feels that this operation is seldom, if ever, indicated, 
and that on the basis of his results the Bankart or Putti-Platt operations 
consistently yield satisfactory results in over 95 percent of cases treated 
(Ed. note; It would seem from these reports that the difference in 
pathology encountered in the shoulder joint subject to recurrent disloca- 
tion is one of degree. Detachment of the labrum, stripping of the anterior 
capsular attachment to the scapula, and defects in the posterior humeral 
head may be present singly or in combination, depending, perhaps, on the 
forces and direction of initial injury, the frequency of redislocation, 
and the duration of the disability. In the American Air Forces, during 
World War II, there were about 20 percent failures following the Nicola 
repair. As these cases were not treated by a single surgical team, but 
by many individuals of varying surgical abilities, a portion of these 
failures may conceivably be the result of faults in reparative technique. 
No statistics are available as to the percentage of failures following 
Bankart, Magnuson or Roberts repairs). 
The Bankart approach and the Bankart repair of the labrum, in all in- 
stances where it was found detached, (70 percent), was used by Watson-Jones 
(8) in 51 cases of recurrent dislocations of the shoulder joint. In addi- 
tion, he routinely overlapped and double-breasted the capsule and shortened 
the subscapularis muscle in a manner similar to that described by Platt. 
All of these cases were successful. In an additional patient in which the 
approach was made over the superior aspect of the joint, only the Bankart 
repair was done. In this case operation failed within a 6-month period. 
He believes that the inference is obvious; that the success of the Bankart 
operation is due more to the operative exposure and subsequent resuture 
limiting external rotation, than to the repair of the labrial lesions. 
Gallie and LeMesurier (9) introduce a method of fascial repair of 
the detached labrum. A 16-inch x 1-inch strip of fascia lata is threaded 
through the scapular neck at the glenoid rim anteriorly, passed through the head of the humerus and is fixed to the coracoid fossa. Threading 
the fascia is done by first passing a long l/U-inch drill point with eyelet 
from front to back through the scapular neck until the drill point pro- 
trudes from the skin posteriorly. This puncture wound is then enlarged 
slightly with a scalpel down to bone, the fascia knotted securely at one 
end, and the other end fixed to the drill point eyelet with heavy silk, 
and drawn anteriorly through the scapula tunnel until the knot impinges 
on the posterior scapular neck. This fascial buttress is entirely extra- 
capsular and has the double function of fixing the detached capsule to 
the glenoid rim and reinforcing it across the anterior joint surface. In 
a series of 175 operations performed since 1926 they report 7 recurrences. 
Two of these were the result of sufficient violence to dislocate a normal 
shoulder. The other failures were due to faulty surgical technique, in 
that the fascial strut was placed too low, permitting the humeral head to 
luxate anteriorly over it. All of the patients returned to their ordinary 
occupation, 80 of them being members of the armed forces who were returned 
to duty and later demobilized without pensionable disability. 
Richardson (10) attempts to increase the functional articular area of 
the shoulder joint and thus discourage dislocation by elongating and shift- 
ing the coracoid process downwards and outwards, A brief description of 
this operative procedure is given. In a series of 16 operations he reports 
a successful result in 12 cases over a 1 to 2 year follow-up period. 
Because it is based on sound physiological and mechanical principles 
and does not endanger vital structures in its surgical approach, Juers (11) 
prefers the Magnuson-Stack procedure for the correction of recurrent dis- 
location of the shoulder. He treated 3h cases by this method, and in those 
cases in which careful follow-up studies were available 15 to 18 months 
after surgery, the results were excellent. 
Similarly, Giannestras (12) reports success in 91*6 percent of a series 
of 31 Magnuson-Stack subscapularis tendon transplantations# The author ad- 
vocates more general use of this method as he feels that Magnuson’s concept 
of lack of muscle balance resisting downward and forward displacement of 
the humeral head is sound# The operative procedure is described with a 
modification in a manner of attaching the tendon to the greater tuberosity. 
The Putti-Platt operation for recurrent dislocation is described in 
detail in a beautifully illustrated report by Osmond-Glark (13). A history 
of the development of this operation is presented. 
Warrick (Uj.) reports three cases of acute posterior dislocation of 
the shoulder. Because this injury is unusual and the physical signs are 
often masked by soft tissue swelling, it is frequently overlooked during 
the patient's first visit to the physician. In two of his referred cases, 
the pathology remained unrecognized for 5 weeks. In the third patient an 
immediate diagnosis was obtained by vertical x-rays of the joint. He 
recommends, for more rapid diagnosis than is possible with stereoscopic 
films which require drying before reading, a vertical projection using a 
curved cassette in the axilla. 
Axial roentgenograms of the shoulder joint are also recommended by 
Knutsson (15)• He places the patient on his back with the arm abducted. and directs the central rays horizontally toward the axilla, the film 
being placed in epaulet position on the shoulder. 
Zadik (16) reports a case of recurrent posterior dislocation of the 
shoulder joint. In his patients the initial dislocation resulted from a 
direct blow to the anterior shoulder during a boxing match, and recurrences 
always resulted when the am was directed forward. 
Because of the difficulty of maintaining the head of the humerus in 
position after surgical correction of old dislocations, Neviaser (17) uses 
a long vitallium wood screw transfixing the head and glenoid. The screw 
is removed in three or four weeks and motion of the arm encouraged. He 
reports the successful use of this procedure in six cases, in none of 
which could harmful changes to the humeral head or glenoid fossa be dem- 
onstrated roentgenographically as a result of the screw. 
Brockbank and Griffiths (18), describe the various manipulative methods 
of reducing dislocation of the shoulder joint as advocated by Ambroise Pare 
Six manipulative methods are quoted verbatim from an English 
translation of his collected works published in 16?8. The article is il- 
lustrated with reproductions of medieval woodcuts. 
Acromio-Clavicular Joint 
Moore (19) describes an original operative treatment which he has used 
in 2k cases of acromio-clavicular joint injury. He advocates its use in 
all but minor injuries to this joint. Through a Roberts approach the acromio- 
clavicular joint is exposed and its cartilaginous surface excised down to 
bone. The clavicle is fixed to the coracoid with double No. 26 stainless 
steel wire looped through drill holes in both structures after reduction 
of the acromio-clavicular joint. Accurate reduction of the acromio-clavicular 
joint is essential before this procedure is done. Postoperatively, a Vel- 
peau type support is used for two weeks, a sling for two weeks and active 
exercises begun. The average convalescent period for these cases is about 
k0 days. This operative procedure was devised originally to relieve dis- 
abling arthritis of the acromio-clavicular joint, and was later found use- 
ful also in the treatment of acute separations and injuries of this struc- 
ture. He believes that the development of a painful arthritic joint fol- 
lowing dislocation is inevitable, and that this surgical procedure at the 
time of original injury will eliminate this disabling sequela. Microscopic 
section made on 20 acromio-clavicular joints in his series all showed the 
same basic findings in varying stages of progress. They consisted essenti- 
ally of exuberant proliferation of young fibrous tissue from organized 
hemorrhage into the joint, fragmentation, and degeneration and fibrous 
overgrowth of cartilage. Grossly, loose bodies and cartilaginous flakes 
were found and frequently the entire articular surface of either the 
clavicle or acromion, but especially the clavicle, would be practically 
detached as the result of undermining by creeping granulomatous tissue. 
All of his patients have been followed for more than a year and although 
the author does not claim that these shoulders have been restored to nor- 
mal, he feels that the results in his series seem to represent a definite 
improvement over previously reported results. Bosworth (20) reports an end-result study of 8 cases of acromio- 
clavicular separation treated by the screw suspension method which he in- 
troduced in 19U2* These cases were the earliest ones operated upon by 
the author. Nine additional cases, treated by other surgeons are reported, 
but not included in the summary of end-results. Of his cases, six were 
completely successful from an anatomic, economic and functional aspect. 
One case was equally successful, except that the screw was not inserted 
deeply enough and jmlled out slightly, and iri another case the screw broke 
and the operation was considered a failure. Several facts are disclosed 
by this study; (1) there has been no migration of screws, (2) the flanged 
screw, designed by the author, if placed through both cortices of the 
coracoid does not pull out, (3) maintenance of reduction is dependent 
upon firm healing of soft parts and not upon the screw, (1*) reduction of 
the dislocation must be complete before the screw is inserted to eliminate 
excessive mechanical stress upon it. Early mobilization of the extremity, 
a short convalescent period and minimization of disability, are given as 
advantages of the screw suspension method. 
A special plaster jacket incorporating an axillary crutch, is de- 
scribed by Morrison (21) as a method of treating acromio-clavicular dis- 
locations. The method allows the patient free use of both arms and per- 
mits his immediate return to work if of a non-industrial nature. Good 
anatomic, and functional results are reported in a series of six consecu- 
tive cases, treated by this method. 
DEGENERATIVE LESIONS OF THE SHOULDER JOINT 
The pathologic changes that, occur in degenerative lesions of the 
tendons, capsule and cartilage of the shoulder joint are reviewed by Neu- 
feld (22). In his opinion, these changes are primarily metabolic witH 
Heredity contributing an important role. Trauma, although of significance, 
cannot be the sole cause of degeneration, for the lesion is less frequently 
seen in men than in women and younger individuals subject to greatest trauma 
are unaffected, or only briefly so. Symptoms most commonly occur in the 
age group from UO to $0 years, and begin as a slowly progressive ache in 
the shoulder, followed by a period of 8 to 2k hours of relative comfort 
before acute symptoms appear. During the acute pain if there is no evi- 
dence of calcification, the author's choice of treatment is the intermittent 
application of ice caps directly to the shoulder. These are applied for 20 
minutes and removed for 20 minutes for a day or two when the acute symptoms 
usually subside. Penicillin and sulfa drugs are given if fever and leuko- 
cytosis is present. Movements which cause pain are strictly not prescribed, 
but are encouraged in planes where it is painless and are as rapidly in- 
creased in range as pain within this range disappears. Exercises are al- 
ways of the active type. In those cases where calcification is demonstrated, 
surgical removal gives the most rapid long-term relief. In both types, with 
or without calcification, the immediate results following treatment are 
usually good. In the chronic type this function may persist for many months. 
These cases are apt to be overtreated in an attempt to hasten recovery, and 
excessive x-ray, diathermy and massage may actually prolong the disability. 
Temporary relief of discomfort can usually be obtained from stellate gang*- 
lion blocks, but in other patients time alone often seems to be the healing 
factor. Lefevre (23) recommends the use of low-voltage x-ray in the treat- 
ment of "bursitis, neuritis and myositis" of the shoulder. He uses the 
following technique. With the patient supine and the tube placed 30 cm 
above the shoulder, and using 90 KVP, U MA and a 2 mm aluminum filter, 
exposure is given for 5 minutes. The exposure is repeated with the patient 
on his face and occasionally a third dose is given laterally. A maximum 
of 3 weekly treatments of 3 doses is given. He states that relief usually 
results from one or two treatments. 
The etiology and pathogenesis of calcification of the supraspinatus 
tendon is reviewed by Norwich (2ii). He describes in detail the treatment 
of this condition in its acute form by multiple needling, a form of therapy 
that has been used with various modifications for the past 35 years or 
more. The rationale of multiple needling of the calcific deposit depends 
upon the production of local hyperemia. In addition the soft calcific 
deposit is allowed to "overflow its banks", disseminating it into sur- 
rounding planes for more rapid absorption. He emphasizes the importance, 
following needling, of immediate and continuous movements of the shoulder 
under the instruction of a. trained physical therapist. Although pain may 
be increased following treatment, it is short-lived and all pain disappears 
in an average of 10 days. In acute cases one needling usually suffices, 
in subacute forms it may be necessary to repeat two or three times. Fail- 
ures are due to inadequate infiltration and needling and to lack of imme- 
diate and daily shoulder motion. 
(Ed. notes Excision of the deposit under local anesthesia, which 
consumes only a little more time than that required in the needling pro- 
cess, seldom increases postoperative discomfort and gives immediate re- 
lief.) 
Behrend (25>) condemns the indiscriminate manipulation of the "frozen 
shoulder" under anesthetic in an attempt to mobilize it in one sitting. 
The physician who utilizes this method has not intelligently evaluated the 
status of the ligaments, tendons and muscles surrounding the joint, and is 
not cognizant of the stage of inflammatory reaction of all tissues involved. 
Manipulation results in tearing and stretching of these weakened structures, 
producing minute and larger hematoma which result in new adhesions as pain- 
ful and disabling as the previous ones. He divides frozen shoulder into 
two typesi a painful and a painless one. Treatment of the former should 
be conservative, using minimal long-wave diathermy, various forms of local 
heat applications, and liberal use of sedatives and salicylates. It may 
take weeks to bring this phase under control and the patient must under- 
stand this fact to cooperate properly. When pain has subsided, more ac- 
tive therapy is indicated. After preliminary treatment with long-wave dia- 
thermy or infra-red radiation for about 10 minutes, sinusoidal current 
is used for a period of 15 to 2£ minutes followed by massage. Mild passive 
stretching and active exercises are begun, and the amount of force used 
in the passive stretching varies with the patient's tolerance and reaction 
to previous treatment. Stretchings must be postponed if increased pain 
results. When definite improvement has resulted from this graduated form 
of treatment and musculature has been restored to normal, treatments may 
be discontinued. Spontaneous improvement will continue, but the patient 
should be rechecked occasionally to guard against possible flare-up. 
330 Mason (26) reports favorable results in the treatment of "frozen 
shoulder" by stellate-ganglion block. Twenty cubic centimeters of 1/2 
percent novocaine is injected into the ganglion once or twice weekly 
for several weeks, A case receiving this treatment is presented. 
Other Conditions of the Shoulder 
As the basis of a clinical report on common conditions of the shoulder, 
Larson (27) reviewed over 60 articles on this subject, published between 
19UU and 19U8. Calcification and rupture of the musculotendinous cuff, 
periarthritis, frozen shoulder, and dislocation of the shoulder and acromio- 
clavicular joint are discussed. 
Hitchcock and Bechtol (28) focus attention on the importance of le- 
sions of the long head of the biceps as a cause of pain and disability 
of the shoulder joint. Their paper supported by excellent clinical and 
anatomic studies convincingly demonstrates the importance of this dis- 
abling condition. Four representative cases of biceps peritendinitis are 
discussed in detail. They have developed a surgical procedure, used on 
26 cases having this disease, with gratifying results. The method con- 
sists essentially of fixing the tendon of the long head of the biceps to 
the bicipital groove and resecting the portion proximal to the point of 
fixation. After studying the humeri of man and other primates, the authors 
conclude that the normal anatomical mechanics of manls biceps tendon is 
faulty. The intertubercular groove, during man's evolution from the ortho 
to the pronograde position, has shifted medially, and consequently the 
tendon occupies a very insecure position, subject to direct trauma and to 
the trauma of everyday function. In addition, variations in the depth of 
the bicipital groove and the angle of its medial wall, and the presence of 
a supratubercular ridge cause trauma to the tendon. 
Fair bank (29) states that downward subluxation of the humeral head is 
a frequent finding following fracture of the upper end of the humerus. 
Radiographic evidence of this abnormality was present in 12 cases of a 
series of 115 fractures of the proximal humerus treated at the Manchester 
Royal Infirmary. Although the subluxation often disappeared spontaneously, 
it may persist and cause disability. He attributes the subluxation to 
gravitational pull against scapulo-humeral muscles which have lost normal 
muscle tone, and recommends the use of a triangular sling or a shoulder 
spica in these injuries instead of the commonly used collar and cuff sling. 
To correct dropped shoulder resulting from paralysis of all shoulder 
muscles, Spira (30) fixes the tip of the scapula to the 6th rib. This 
procedure stabilizes the shoulder and corrects the abnormal inclination of 
the head and neck to the affected side. The scapula is fixed to the rib 
by notching its tip so that it forks the rib, or by passing the rib through 
a tunnel in the scapula. vVire loops used in his original case loosened 
and the method was abandoned. 
Lurje (31) states that when the "upper primary fasciculus" of the 
brachial plexus is disrupted by trauma, the treatment of choice, as in the case of any other peripheral nerve, is end to end suture of the 
severed nerve trunks after resection of neuroma and scar tissue. In 
many of these injuries, however, the defect between nerve ends after 
resection makes direct suturing impossible. Because recourse to trans- 
plants in these cases does not appear to hold much promise, he uses 
neighboring nerves as neurotizers, cutting the donor nerve as far away 
from the zone of injury as possible and attaching it to the degenerated 
recipient nerve. The nerves chosen as neurotizers obviously are those 
which can be used without further impairing the function of the extremity. 
He has used the following neurotizers with considerable success; the long 
thoracic to the suprascapular, the anterior thoracic to the musculocu- 
taneous, and the tricipital branches of the radial nerve to the axillary 
nerve. Before these donors are utilized, clinical and electr©physiologic 
tests are made to establish that they have sufficient potential capacity 
as neurotizers, and to confirm complete degeneration of the recipients. 
A detailed description of the operation performed on a 20-year old female 
with upper brachial plexus injury is presented. This case illustrates 
successful use of the anterior thoracic, long thoracic and radial nerves 
as neurotizers. 
Bateman (32) reports successful results from transplantation of the 
acromion process with its trapezius muscle attachment into the upper end 
of the humerus. His patient had had complete loss of shoulder abduction, 
with good hand and forearm function following a traction injury, which 
irreparably damaged the upper roots of the brachial plexus. 
Butterworth and Carpenter (33) report a case of bilateral slipping 
of the proximal humeral epiphysis due to severe trauma. Their patient, 
a boy of 16, was thrown from the rear of a truck probably landing on his 
outstretched arms. The resulting deformity resembled bilateral subglenoid 
dislocation. Reduction was accomplished without difficulty by manipulation. 
A good range of bilateral shoulder motion was present after 20 weeks with, 
however, marked deltoid atrophy on the left side# 
Bilateral rupture of the tendon of the long head of the biceps brachii 
muscle is reported by Christie (3h)• Surgical repair consisted of looping 
the tendon through the lower margin of insertion of the pectoralis major 
tendon and suturing it on itself. In this patient ruptures did not occur 
simultaneously but were the result of separate injuries occuring over a 
period of a year, and in both instances the injury followed the lifting of 
a heavy object. The author tabulates the types of treatment, and the 
various operative repairs used by others in the management of this dis- 
abling injury. 
Rossignol (35) reports the case of bilateral congenital pseudarthrosis 
of the clavicle in a 22-year old girl whose main complaint was shoulder fa- 
tigue. Treatment consisted of fusion of the scapula to the Uth rib. Follow- 
up study 7 years later showed 75 percent normal movement of the shoulder 
girdle on both sides. The patient had no functional complaints. 
Cervical Intervertebral Discs 
Milner (36) believes that many cases of cervical root irritation from 
prolapsed discs and osteophytic growths are overlooked. These patients appear to suffer from a ’’disease of symptoms rather than of signs”. Signs 
may be, and probably are present, but the examiners powers of recognizing 
them are at fault. In addition, other injuries may be sustained simul- 
taneously which prolapse and overshadow the effects of the latter. It is 
also difficult, if not impossible, to examine in detail muscles supplied 
by the posterior primary divisions. Again, effects may involve bilateral 
groups of muscles leaving no basis for comparison of the two sides. He 
suggests that the diagnosis and successful treatment of root lesions can 
be most effectively accomplished only after correlating the combined con- 
tributions of experts in the many branches of medicine concerned with the 
problem. 
Bucy, Heimburger and Oberhill (37) emphasize the importance of early 
diagnosis and treatment of cervical disc herniation. They report four 
cases of median disc protrusion, all occurring in males, and present a 
thorough discussion of the symptomatology, types of herniation, differ- 
ential diagnosis, etiology and treatment of cervical disc protrusions. 
All of their patients were active males between the ages of 33 and ££ 
years, indicating indirectly that trauma is responsible for these injuries, 
although in only one case did symptoms definitely follow known neck in- 
jury. Whereas upper extremity involvement is predominant in lateral pro- 
trusions, in median protrusions, spasticity of the lower extremities and 
disturbance of equilibrium are dominant, with minimal or no neck or upper 
extremity disturbance. It is most important that these lesions be dif- 
ferentiated fron multiple sclerosis, primary lateral sclerosis and amyo- 
trophic lateral sclerosis for obvious reasons, but their confusion with 
a cord tumor is of little importance as both the disc and tumor are 
treated surgically. Treatment in the author’s cases consisted of surgi- 
cal removal of the protruding disc material transdurally through a bi- 
lateral laminectomy, of at least two vertebrae. In none of their cases 
did they feel that bone graft or other stabilizing procedures were indi- 
cated. The prognosis should be excellent in cases diagnosed and treated 
early. All of their patients were able to return to work and have shown 
steady improvement. 
A review of the cervical disc syndrome and its differential diagnosis 
by Fields (38), scans the literature on this subject. Shoulder and neck 
pain is a common complaint and often a difficult problem, and frequently 
the diagnosis offered seems to depend upon a field of special interest of 
the examining physician. Thus the orthopedist, neurosurgeon, cardiologist, 
and general practitioner vary considerably in their statistics as to the 
cause of shoulder and neck pain. In recent years, there has been increas- 
ing awareness that a high proportion of these disabilities are due to her- 
niations and other abnormalities of the cervical intervertebral discs. 
The author emphasizes the possiblity that any disease process of the cer- 
vical spine or shoulder may cause spasm of the scalene muscles and thus 
supports the belief of Nachlas, Raney and others that most cases of sca- 
lenus anticus syndrome are secondary to cervical intervertebral disc ab- 
normalities • 
The successful results obtained by various British surgeons in the 
manipulative treatment of the neck for cervical arthritis, has encouraged 
LeVay (39) to try this method in cases presenting unequivocal evidence 
of prolapse of the cervical disc. He treated six patients by this method with immediate and dramatic recovery in five cases. The sixth patient was 
unaffected by manipulation but was relieved of symptoms following a 72- 
hour period of skull traction. He states that manipulation is indicated 
only if pain is present, and is not indicated for paresthesia alone. The 
fear of producing cord symptoms, he states, is without grounds in purely 
monoradicular syndromes. After observing and performing many cervical 
manipulations, he knows of no patient in whom cord symptoms developed fol- 
lowing this therapy. 
Headache, as a common symptom of cervical disc lesions, is discussed 
by Raney and Raney (UO). They report U cases of intervertebral disc patho- 
logy in which headache was the chief complaint. (In one case this was not 
admitted by the patient until after the disc was removed). The headache 
produced by pathologic changes of the cervical disc may be constant and 
vary only in intensity; it may be periodic, presenting itself only during 
certain activities of the patient; it may be so mild as to pass unnoticed 
until exacerbated by nervous strain, muscular fatigue or during the menses 
when a reduced pain threshold occurs; it may be of, short duration occurring 
as a stinging, tingling sensation radiating over the occipital or parietal 
regions. At times the patient may complain of headache when actually the 
discomfort is in the neck. The extreme variation in intensity, frequency, 
radiation, projection and location, prevents a clear definition or classi- 
fication of this symptom. Examination of the patient having headache due 
to a cervical disc lesion reveals characteristic signs. Neck muscles may 
be spastic with cervical scoliosis or lordosis, or the neck may be main- 
tained in a slightly tilted or rigidly fixed position. More important are 
the areas of localized tenderness in the suboccipital, cervical, shoulder 
and elbow regions. No detectable motor, sensory or reflex changes may be 
present. If present, they indicate later stages of disc protrusion, and 
the associated shoulder and arm discomfort overshadows any headache that 
may be present. An explanation of the mechanism producing headache as a 
result of disc pathology rests on present knowledge of referred pain, dif- 
fusion of pain and mental projection of pain, and not necessarily on evi- 
dence of direct neural connection between the disc and the area in which 
the patient believes the discomfort to be located. 
Jackson iUl), in a review of 200 cases of cervical root irritation, 
found that Half of them had complained of intermittent headache, many hav- 
ing been treated for migraine. A history of trauma was given in 9U percent 
of the cases, with symptoms dating from the onset of trauma to many years 
following injury. The discomfort varies from pain radiating upwards from 
the posterior cervical region, or base of the skull, to the side of the 
head and mastoid region or ears, to blurring of vision, dizziness and nau- 
sea. Most of the patients complained of being awakened in the early hours 
of the morning by the onset of headache. X-ray examination of the cervi- 
cal spine, using the technique described by Davis, disclosed obliteration 
of the normal forward curve in 70 percent of the cases with 20 percent 
showing segmental reversal of the curve. Ninety percent showed forward 
subluxations and p6 patients had backward subluxations which meant that 
a large number had both forward and backward displacements. Thirty-five 
percent showed x-ray evidence of ruptured discs. Treatment was conser- 
vative in all cases. Because in so many patients, onset of discomfort 
in the early morning hours indicated improper sleeping posture, the au- 
thor devised a ''contour'* pillow fitting into the natural curve of the neck, -which she states has been the greatest adjunct in the treatment 
of cervical root irritation. 
Cervical Cord Injur; 
Barnes (U2) reported 22 cases of cervical spine injury. Fifteen of 
his patients had flexion injuries, 8 of these being dislocations, U crush 
fractures of the vertebral body and 3 acute retropulsion of the interver- 
tebral disc. Six injuries were of the hyperextension type in patients 
with arthritic spines. In one case the injury consisted of a dislocation 
due to hyperextension force. Of interest is the age group into which the 
flexion and the extension injuries occurred. In the flexion* group the 
oldest patient was £0 years of age, in the hyperextension group all in- 
juries were incurred in patients over 50 years of age. Elderly patients 
are prone to extension injury because of (1) the tendency, in advancing 
years, to kyphosis of the dorsal spine with compensatory cervical lordo- 
sis, and (2), the loss of normal cervical mobility due to arthritic 
changes in the joints and ligaments which prevents a protective flexing 
of the neck in the event of a fall. These patients show surprisingly 
little bone or spinal cord injury, yet paraplegia and death within a few 
days occurred in £ of the 6 cases treated by the author. He describes 
the mechanism of injury as being an extension force producing rupture of 
the anterior ligament with or without avulsion of a small flake of bone 
from the upper margin of the inferior vertebra. Sudden traction force is 
applied to the cord during the period of hyperextension and the return to 
normal alignment when the striking force is removed. 
Taylor and Blackwood (1*3) report a case of hyperextension injury to 
the cervical cord which supports the observations of Barnes. They believe 
that in those cases of paraplegia following trauma, in which there is little 
or no x-ray evidence of bone injury, a hyperextension injury should be sus- 
pected. 
In an editorial, Jefferson (kh) comments on the concept of Barnes, 
Taylor and Blackwood as to the mechanism of extension injuries to the cer- 
vical cord. He believes that their conclusions will probably be substan- 
tiated by other observers. However, "the real problem of spinal injury 
is not altered materially by change of opinion as to what the agent of 
injury may be”. 
That flexion type injury to the cervical cord may be produced without 
roentgenologic evidence of fracture or dislocation is illustrated in a 
case report by Gordon (k5)• His patient developed a myoclonic phenomena 
in the form of myokymia and fibrillary contractions of the flexors and 
extensors of the arms. This unusual muscular phenomena which was noted 
following examination of his patient immediately after injury, was still 
present in a follow-up examination 11 years later. 
Cervico-brachial Nerve Irritation 
Dedichen (i*6) notes that the patient with shoulder pain of sudden on- 
set, with radiation down to the elbow, will often show, especially in early stages of the condition, findings characteristic of localized nerve root 
irritation i. e. hyperesthesia in Cii-£ area, exaggeration of the deep re- 
flexes of the arm, diminution of the abdominal reflexes on the same side, 
intensification of pain on flexion of the neck to the side of pain and a 
positive jugular vein compression test* This pain may produce a typical 
picture of humeroscapular periarthritis, with calcification 'of the rotator 
cuff. He believes the formation of calcium to be secondary to reflex 
arterial constriction as the result of the irritation which results in 
tissue degeneration. 
Following a detailed anatomic study of the scalene muscles and as- 
sociated structures, Kirgis and Reed (i*7) were able to demonstrate several 
factors which apparently are of importance in the production of the scalene 
syndrome. 1. Irritation of the lower components of the brachial plexus 
by elevation of the first rib through activity of the scalene muscles. 
2. Irritation of the adjacent nerve root and subclavian artery by com- 
pression of the contracted posterior components of the anterior scalene 
muscles. 3# Irritation of the brachial plexus, especially the 7th and 
8th cervical and 1st thoracic nerves, by traction across the anterolateral 
margin of a spastic medial scalene muscle. 1*. Irritation of the lower 
brachial plexus trunk by pressure anteriorly of the scalenus minimus mus- 
cle or the vertebrocostal ligament. They do not believe that purely ana- 
tomic relationships are responsible for spasm of the scalene muscles, but 
that these relationships may be so patterned that development of symptoms 
follows spasm of these muscles. In cases where surgical treatment is in- 
dicated, they advocate complete resection of the major portion of the sca- 
lenus anticus muscle* when these structures are present. Anterior scaleno- 
tomy alone has frequently yielded poor results because it has constituted 
the treatment of only one of the possible manifestations of a more serious 
disease• 
Telford and Mottershead (U8) believe that although the diagnosis of 
a pressure lesion at the cervico-brachial junction is usually simple, the 
causes of pressure are so varied and obscure that it is often difficult or 
impossible to predict them. For this reason, when surgery is advised, the 
authors believe it should be performed through an incision generous enough 
to allow thorough investigation of the causes of pressure. Their belief 
is based on the clinical and surgical findings in 122 patients personally 
treated. At surgery symptoms were found to be due to the presence of a 
cervical rib in 70 cases, to abnormal disposition of the scalene muscles 
in 8 cases, to deformed thoracic outlet in 8 cases, to pressure of fibrous 
band in 12 cases, to cancellous osteoma in 2 cases, and in S cases there 
was no obvious cause for symptoms. In the remaining group, which they 
considered complicated, l£ showed well developed cervical ribs with ex- 
tensive arterial thrombosis, and three of these had aneurysmal dilatations 
of the subclavian artery. In their opinion, too much emphasis has been 
placed on the scalenus syndrome. When pain is due to anterior scalene 
muscle pressure, the pressure is passive and mechanical and is not the 
result of spasm, injury or disease of this muscle. The costo-clavicular 
syndrome has also been over-emphasized. Formalin hardened cadaver and 
fresh post-rigor bodies were studied, and in no instance could the sub- 
clavian artery or brachial plexus be compressed between clavicle and 
rib. Thrombosis of the subclavian sympathetic nerve fioers, and the 
presence of aneurysm is explained as the result of segmental vasomotor 
paralysis of the artery. Judovich (h9) emphasizes the importance of distinguishing between a 
primary scalene syndrome, in which symptoms originate and are due to in- 
trinsic disturbance of the muscle, and a secondary scalene syndrome, re- 
sulting from reflex spasm of the muscle produced by irritation of struc- 
tures in the shoulder girdle or by disturbance of segments innervating 
these structures. Surgical procedures give complete relief in the former 
type, and only partial relief in the latter. The symptoms of the two 
types maybe identical, and in the author's opinion, the most dependable 
method of differentiation is a modification of the novocaine infiltra- 
tion test introduced by Gage in 1939* One and a half to two cc. of 1 
percent novocaine is injected directly into the muscle belly, using 3/8 
to 1/2 inch needle to prevent too great a depth of injection. Within 3 
minutes, in primary cases, response is dramatic, and the more rapidly 
the symptoms disappear, the more likely a primary spasm exists. The neck 
and shoulder is then re-examined the moment pain is relieved. The pre- 
sence of pain in percussion of the cervical spinous processes, or on mo- 
tion of the cervical spine during the relief period, suggests a secondary 
scalene syndrome. Repeated novocain* infiltrations are recommended, and 
the results evaluated before final differential diagnosis is made. Fre- 
quently these repeated injections will produce sustained relief of symp- 
toms in primary cases. 
DePalma (£0) states that the treatment of the scalenus anticus syn- 
drome should be directed both to the etiologic factors and to the con- 
tracted scalene muscle. Mild forms of the syndrome will respond' to con- 
servative measures, such as postural exercises, shoulder and back supports, 
change of occupation, and rest augmented by sedatives and procaine injec- 
tions into the muscle belly. When conservative methods fail, division of 
the scalenus anticus muscle is the treatment of choice. However, because 
many patients refuse surgery, or because surgery is contraindicated the 
author has substituted skeletal traction on the cervical cord. In his 
series of 1? patients in which conservative therapy was augmented by trac- 
tion, all but one was relieved of pain. 
In a similar vein, Donald (£l) reports that a majority of patients 
with scalenus anticus and cervical rib syndromes will respond to con- 
servative therapy. .This treatment includes correction of posture, rest, 
avoidance of strain, physical therapy and analgesic drugs. In about 2£ 
percent of cases symptoms are unrelieved by conservative therapy, and in 
these cases only is surgery warranted. Over a 10-year period he operated 
on h2 patients with this syndrome. On 8 occasions a cervical rib was 
demonstrated, and in these patients symptoms of brachial plexus and sub- 
clavian artery compression were, in general, more severe than if the ano- 
malous rib was not present. Pain is usually the greatest cause of dis- 
ability and is usually felt along the distribution of the internal cu- 
taneous, ulnar and median nerves. It varies in intensity and may be 
sharp, but more commonly is of a dull aching nature, and may involve the 
entire arm, shoulder and neck regions. Circulatory disturbances are usu- 
ally mild unless a cervical rib is present, in which case marked changes, 
including gangrene of the distal extremity, results. Frequently the sca- 
lene muscles are tender to pressure. In chronic states, atrophy of the interosseous muscles may be seen, and the grip is noticeably weak. In 
the differential diagnosis, protrusion of a cervical intervertebral disc, 
cervical arthritis, subacromial bursitis and psychoneurosis, cause the 
most difficulty# 
Haggart (52) treated 20 consecutive patients with cervicobrachial 
pain by conservative methods, and classified the results as excellent 
in 5 cases, good in 12 cases, and fair in 3 cases# Because of the com- 
mon characteristics of cervical pain with radiation to shoulder and arm, 
these cases were grouped together although the diseases were heterogeneous# 
There were 3 cases each of cervical rib, protruded disc, degenerative ar- 
thritis, scoliosis, scalenus anticus syndrome, costoclavicular syndrome 
and hyperabduction syndrome; and one patient with posttraumatic symptoms# 
Most of his patients were treated on an ambulatory basis# The principal 
treatment; consisting of postural exercises was directed toward neck and 
shoulders. Occupational habits were investigated, and if habits were 
found that contributed to faulty posture and muscle stress and strain, 
suggestions were made to correct or omit them# Vitamin B complex was ad- 
ministered three times daily in those patients, usually female office 
workers, where vitamin B deficiency was present# Mild analgesics were 
prescribed as an aid in breaking up the vicious cycle of pain. The age 
of his group of patients ranged from 2k to 60 years, with an average of 
39 years# The ratio of females to males was 3 to 1# In only 15 percent 
of the cases did occupation appear to be unrelated to symptoms. Using 
conservative treatment he was able to restore all of his series of pa- 
tients with varying degrees of disability to usefulness, 1? with good and 
excellent results, the average follow-up period being 15#3 months. 
Bograd and Peters (£3) base their diagnosis of scalenus anticus syn- 
drome on the effect of novocaine injection into the muscle# When temporary 
relief of symptoms is obtained following injection, precautions being taken 
to inject only the muscle belly, they feel that scalenotomy is indicated. 
It is their opinion that conservative treatment yields no better results 
than no treatment at all, as spontaneous remissions of symptoms are com- 
mon. They present 3 cases in which they performed scalenotomy. The re- 
port does not include a follow-up study. 
A case reported by Jonas and Rise (5U) illustrates the inadequacy of 
scalenotomy alone in the presence of prominent cervical ribs. Their case 
is also unusual in that bilateral neuropathic changes in the elbow joints 
resulted from injury to sympathetic nerve trunks passing over the abnormal 
ribs. 
Stevenson (55) reported 12 cases of scalenus anticus syndrome seen 
in a 12-month period. Conservative therapy produced partial to complete 
relief of symptoms in 9 cases. Complete relief in the remaining 3 cases 
resulted following anterior scalenotomy. 
Complete relief of symptoms was obtained in 3 cases reported by Levi 
(56) following division of aberrant fibers of the scalenus medius muscle.’ 
In each instance the abberant fibers, partially muscular and partially 
fibrous, passed anterior to the brachial plexus and inserted posterior to 
the subclavian artery on the first rib. The muscle formed a rigid aperture 
through which a lower branch of the plexus passed. Cervical ribs were not 
present on x-ray examination in any of his cases. (Ed, note: It is apparent that there is still considerable dis- 
agreement as to the significance of the scalene muscle group in the pro- 
duction of cervicobrachial pain. The studies of Telford and Mottershead, 
based on an unusually large series of cases, are significant. Their re- 
port probably comes closer to the solution of this problem than any other 
paper published in 19i$.) 
Batchelor (57) reports a case of malunion of the left clavicle in a 
woman "3d years of age, who developed pain in the shoulder radiating to 
the ulnar aspect of the forearm and hand. Physical findings consisted 
of atrophy of the arm musculature, decrease in temperature of the hand, 
and a reduction in radial pulse volume as compared to the normal side. 
He attributed the symptoms to costoclavicular compression. 
During the routine chest examination of 2619 apparently normal ap- 
plicants for position, Pomerantz (58) noted the presence of a systolic 
murmur over the subclavian artery in 21 individuals. All of the appli- 
cants were of Mexican extraction. The first 11 cases were passed over 
without special examination, because the murmur was considered func- 
tional, A more detailed study was performed on the remaining 10 cases in 
an effort to determine a possible relation of this murmur to extravascu- 
lar compression or obstruction. From this limited clinical material, 
after careful blood and pulse pressure studies, he felt that definite 
extravascular obstruction of the subclavian artery was present. This ob- 
struction was usually related to position of the arm, and a characteristic 
postural attitude. Because progressive obstruction occurred with in- 
creased abduction of the arm, presently recognized forms of the scalenus 
anticus syndrome seemed to be excluded, as an etiologic factor. The ab- 
sence of carotid artery transmission and the variability of obstruction 
with arm position, excluded an intrinsic vascular mechanism as a cause 
for the murmur. Subclavian compression as a cause was discarded because 
the murmur was frequently present with the arm at U5 degrees, the phase 
at which the clavicle is not in close approximation to the first rib. 
Because all of the patients presenting this murmurwere asymptomatic and 
surgical exploration to determine the cause was unjustified, the mech- 
anism producing compression necessarily was a matter of conjecture. 
However, by title the author implies that the murmur was caused by an 
asymptomatic form of scalenus obstruction or some other compressions of 
the arterial trunk, such as that described by Wright. 
Cliffton (59) reports a case of dysfunction of the upper extremity 
in a 35-year old soldier. His symptoms of pain in the arm, numbness, 
tingling and weakness of the hand had been present for five years follow- 
ing a fracture of the clavicle. At surgery a markedly hypertrophied sub- 
clavius muscle was found to be almost completely occluding the axillary 
vein as this vessel passed beneath it. Thrombosis of the vein was not 
present, and simple incision of the muscle at the point of pressure re- 
sulted in relief of symptoms and improvement in function of the extremity. 
Bledin (60) briefly reports a case showing paralysis of the muscula- 
ture of the right forearm and hand, innervated by the ulnar nerve. Al- 
though roentgenograms did not show a definite cervical rib, there was a 
shadow, less dense than bone, extending from the 7th cervical transverse 
process downwards toward the first rib bilaterally, which he was inclined 
to believe was the etiologic factor. A disorder characterized clinically by a peculiar combination of 
painful shoulder disability '-1th homolateral swelling of the hand is dis- 
cussed in an article by Steinrrocker, Spitzer and Friedman (61). This 
shoulder-hand dystrophy of unknown etiology was seen on Tl occasions in 
their series of U2 cases of reflex dystrophy of the upper extremity. 
In the other cases, definite etiologic factors, among them, myocardial 
infarction, trauma, hemiplegia, herpes and arthritis, were responsible 
for the reflex sympathetic changes. Although the precipitating factors 
vary, and in 11 of their cases were undetermined, the clinical picture 
produced is much the same, i.e.j a painful shoulder of sudden or gradual 
onset, followed in several weeks by uniform swelling, pain and stiffness 
of the hand and fingers. After a period of 3 to 6 months in progressive 
cases, pain in the shoulder subsides and the hand swelling resolves. Dur- 
ing this second stage stiffness and flexion contracture of the fingers be- 
comes more pronounced and atrophy of the subcutaneous tissue and intrinsic 
muscles of the hand more noticeable. The previously elevated cutaneous 
temperature subsides. Osteoporosis, patchy in nature, which may not have 
been visible during the early stage, is strikingly noticeable at this time. 
The final stage is characterized by progression of trophic changes in the 
hand, further decrease in skin temperature and diminution of blood flow to 
the extremity. Bone atrophy becomes widespread and diffuse in hand, fore- 
arm and arm. The mechanism producing the shoulder-hand syndrome, regard- 
less of the precipitating factor, is believed to be ”a vicious circle” 
mediated through an internuncial pool of active stimuli in the cord. 
This hypothesis is based on the favorable response, in early stages, to 
interruption of sympathetic pathways by stellate and upper dorsal gang- 
lion block or surgery. Surgery, however, is reserved for those cases 
where repeated sympathetic; olocks give only partial or temporary relief 
of symptoms. 
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61. Steinbrockor, 0., Spitzer, N. and Friedman, H. H.: Shoulder-hand 
syndrome in reflex dystrophy of upper extremity, Ann. Int. Med., 
29s July 19U8 SECTION 17 
HAND AND ELBOW 
Prepared by Victor B. Vare, Lt. Col*, M.C., U.S.A. 
Injuries 
Browne (1) discusses "Effective Procedures in the Treatment of Injured 
Hands to Prevent Crippling Deformities." The management of a hypothetical 
case of hand injury from the trauma to the ultimate restoration of function 
is presented in minute detail. Each of the following is described at length: 
diagnosis of injured structures, preparation for operative procedure, fur- 
ther examination before cleansing the wound, debridement and enlarging the 
wound, approximation of viable ends of divided structures, the dressing, 
and finally rehabilitation. The author emphasizes that a contaminated wound 
must be made clean; an open wound must be converted into a closed one. Other 
procedures, depending upon the condition of the tissues injured and the me- 
thods available for establishing continuity of these tissues, may and should 
be carried out when safety permits. 
Thompson (2) presents an outline of the principles of early management 
of hand injuries. Protection against added infection and protection against 
added tissue damage and deformity are the primary issues. The outline is 
submitted with the commendation of the Committee on Fractures and Trauma of 
the American College of Surgeons at the instigation of the American Society 
for Surgery of the Hand to familiarize the general profession with these 
principles, 
With well chosen case reports Mason (3) emphasizes many fundamental 
principles with regard to treatment of open wounds of the hand. Some inter- 
esting comment occasioned by the case reports, is made upon the following 
considerations: 1, The decision as to whether or not tendon repair should 
be taken as a primaiy operation, 2. Manner of enlarging the wound to obtain 
adequate exposure for repair of nerves and tendons, 3. Use of a blood pres- 
sure cuff to procure a bloodless field, U, Method of handling avulsed and 
crushed skin, 5# Value of compression dressings, 6, The use of a splint 
following surgery of the hand, 7* Interval between time of wounding and 
the primary care and the indication for primary closure of a wound, 8, Im- 
mediate application of a pedicle flap, y, Sxin which has been subjected to 
severe crushing and tearing and lu. Secondary wound closure. 
Detro (h) discusses the important factors in history taking, physical 
examination, and some of the pitfalls in treatment in the form of primary 
care, to extensively injured hands. Some pictures of the before and after 
variety are presented. He also includes the rationale of treatment of var- 
ious types of hand fractures. 
Mason (5) discusses in detail the treatment of both early and late open 
wounds o'f~~the hand. He discusses all of the basic principles and gives his preference for primary closure and tendon and nerve repair if circumstances 
permit and the injury can be cared for within a four hour deadline. He 
discusses the importance of good first aid, that is, control of heramorrhage 
by compression, coverage of wounds with sterile dressings and avoidance of 
secondaiy contamination from the nasal passages and probing, etc. He des- 
cribes how to recognize dead and dying tissues which have to be excised 
during the meticulous debridement. He also describes his method for tendon 
and nerve repair preferring untreated silk suture material on a swaged 
needle* 
Duncan (6) discusses the anatomy, indications for tendon repair and 
evaluation of results in a series of U2 consecutive cases of repair of flex- 
or tendons of the hand divided in the flexor sheaths. Primary and delayed 
repairs are discussed with immediate repair being undertaken where possible 
in which nearly were classified as good results, A small series of 
cases of divided pollicis longus tendons is included. He also presents the 
results of investigations into the pathology of mallet finger, recording 
the exact site of tear (fracture at base of terminal phalanx, and non frac- 
ture type (a) avulsion of the tendon from the base and (b) avulsion proxi- 
mal to this level) and synovial involvement which after healing may result 
in adherence to bone and a poor result. A fully flexed terminal phalanx 
without any power of extension is presented as the main indication for 
operation. 
Mason (7) discusses basic principles pertinent to secondary closure of 
wounds of the hand. He, refers of course, to those injuries that cannot be 
closed primarily because of existing circumstances. Conversion of an open 
wound into a surgically clean wound at the earliest moment is to be strived 
for. Debridement, or removal of dead and dying tissue can be performed 
early or late. Wounds, of course, are left open if danger of locking up 
infection exists, Cover of the cleansed and debrided wound with a volumi- 
nous dressing and putting the part at rest with a splint are important as- 
pects of therapy. He describes what he calls a "universal hand splint", 
which looks like a derby hat with a forearm attachment, over which the hand 
is moulded. The hand is then examined preferably in the operating room U-6 
days later and secondary closure performed if appearance permits. Four 
case reports are included. 
Van Demark (8) calls attention to the fact that although transscapho- 
perilunar dislocation of the carous is relatively frequent, it has received 
little recognition as an entity* He notes further that the lunate and prox- 
imal scaphoid fragment have been excised under the erroneous impression that 
they were dislocated* Emphasis is laid upon recognition. The author be- 
lieves that early closed manipulation and reduction is the treatment of 
choice in this type of injury. 
Waugh and Yancey (9) note the rare occurence of carpo-metacarpal dis- 
locations with particular reference to simultaneous dislocation of the bases 
of the fourth and fifth metacarpals, and with an extensive review of the 
literature, 2 such cases are reported. Attention is called to their impor- 
tance in maintaining the proper mechanics of the hand and the restoration 
of muscle balance. One case presented was reduced by closed and another by 
open reduction, the latter being held in position by dual Klrschner wire 
fixation of the fourth and fifth to the third metacarpals* Sampson (10) reports three cases of isolated dislocation of the lesser 
multangular bone. In searching the literature, the author was able to find 
only 8 previously reported cases. Of the total of 11 reported cases, 10 
were dorsal, 1 volar. The mechanism of injury was strikingly similar in 
each of the author’s cases. The diagnosis is established by clinical exam- 
ination, by roentgen examination, of which the routine posteroanterior view 
is of the most value, and by careful comparison with roentgenograms of the 
untraumatized, presumably normal wrist. No rule of treatment is established. 
These methods were mentioned;, closed reduction, open reduction and excision. 
Immerman (11) reviews the literature and presents a beautifully illus- 
trated case report of dislocation of the pisiform. In cases which do not 
respond to splinting and in chronic cases, surgical excision of the pisi- 
form is recommended. 
Howie (12) presents a method of treating mallet finger with the proxi- 
mal interphalangeal joint in flexion. It involves the use of ordinary plas- 
ter bandage, applied in two sections, the first to the proximal two phalanges 
and the second to the distal phalanx. The two sections are then joined with 
more plaster bandage, the distal interphalangeal joint being held in hyper- 
extension. 
Sandison (13) discusses some of the basic principles of treatment of 
supracondylar fractures in children and adults and their complications, such 
as delayed ulnar palsy, Volkman's ischemic contracture, and decrease or in- 
crease in carrying angle. He stresses the need for recognition and open re- 
duction with wire fixation in capitellum fractures in children. Dislocation 
of the head of the radius is to be watched for closely. Where comminution 
of the radial head exists, excision and removal is recommended. Continued 
painful elbows presenting evidence of traumatic arthritis should be consid- 
ered for arthroplasty or fusion in a position most suitable to the patient. 
Railton (lu) reports a case of compound dislocation of an elbow joint, 
uncomplicated by fracture. The humerus protruded thru a skin laceration 
posteriorly. Debridement was performed with suture of the posterior capsule, 
the tom triceps insertion and anterior transplant of the ulnar nerve. The 
skin was closed secondarily several days later by double pedicle shift and 
split thickness skin graft. End result of function is not reported. 
Milch (16) discusses the incidence of rupture of the biceps brachii at 
various levels and reports a case of solution of continuity at the muscle's 
insertion. Operation was performed and because of degenerative fraying at 
the distal tendinous portion repair could only be accomplished by using a 
fascia lata tube replacement. The proximal portion was sutured to the lower 
end of the biceps and the lacertus fibrosis, the distal end drawn together 
with a silk thread and pulled down to a hole prepared in the radius to which 
it was tied, together with the remnants of the biceps insertion. Plaster 
immobilization was left on for three weeks, and gentle active and passive ex- 
ercises commenced at the end of nine weeks. At the end of four months power- 
ful supination was possible and the patient returned to his former occupation 
as a truckman. 
Tanzer (16) stresses the importance of immobilizing the burned hand in 
the functional position from the very onset. Early replacement of constricting or unstable scars is most important in restoring proper nutrition and 
avoiding contractures. Appropriate elastic splinting should be used not 
only to prevent contractures but also to correct contractures if they 
develop• 
Marks (17) presents a case of trauma to the wrist producing a compound 
perilunar dislocation of the carpus and anterior dislocation of the wrist. 
Despite early debridement, suppuration supervened, delaying a wrist fusion 
procedure, When this was performed (no mention of how long healing had 
existed prior to undertaking this procedure), a pocket of encysted pus was 
encountered, A bone graft from the tibia was used and with antibiotics 
postopera lively, healing per primum ensued. It was noted that good func- 
tion of the hand, except for a stiff thumb, resulted. 
Ratliff (lb) presents a review of forty five cases of mallet finger re- 
vealing that the subjective end results are good, but, contrary to certain 
authorities, only hh% healed in a perfect anatomical position. 
Infections 
Pilcher and Dawson (19) discuss the principles and practice of the treat' 
ment of infections of the fingers and hand. Acute infections of the skin and 
subcutaneous tissues of the fingers and hand are treated by immobilization 
during the diffuse phase of the infection. Operation is delayed until pur- 
ulent material is localized and its sole function is its evacuation. Paro- 
nychia, a subcuticular infection, can be adequately treated without sacrifice 
of the healthy nail. Incisions to relieve tension in the stage of cellulitis 
is condemned and together with delay in starting treatment are causes of 
prolonged disability. Systemic penicillin is used to control spread of in- 
fection and locally to accelerate healing. It is thought to delaysoperation 
of slough but to prevent spread of bone infection. 
Loudon, Miniero and Scott (2o) make a preliminary report of sixty nine 
consecutive cases of infections of the hand, describing their classification, 
pathology, pre-operative, operative and post-operative treatment. "Where 
possible, they practice complete excision of dead and dying tissue with pri- 
mary closure, thereby decreasing healing time considerably, where primary 
closure is not possible, subsequent pinch grafts are used. Chemotherapy and 
immobilization in plaster of the affected part only are used in conjunction 
with excision and primary suture technique which must be meticulously com- 
plete, The possibility of recurrence of local infection proved not to be 
the main danger. Extensive exposure, however, increases the possibility of 
damage to important structures, particularly if carried out by inexperienced 
surgeons, 
Van Demark, Koucky and Fischer (21) discuss peritendinous fibrosis of 
the dorsum of the hand, persistent swelling of the dorsum of the hand occur- 
ring shortly after local injury being the predominant clinical feature. In 
severe cases, the back of the hand has a smooth stretched appearance. Nor- 
mal bony landmarks are absent and the swelling is firm. Such a swelling 
may persist for weeks or months. There is inability to flex the fingers 
while motions of the thumb are normal, A dull pain, increased by local pres- 
sure is noted. X-ray findings are negative. In two cases reported, patho- 
logical specimens revealed evidence of old and recent hemorrhage with fibrous tissue proliferation and organization in the area around the extensor tendons 
The tendons themselves are also infiltrated by fibrous tissue. Numerous 
forms of treatment have been suggested. 
Luckey and Moon (22) quote Kanavel (23) in mentioning three types of 
edema of the hand, 1. recrudescing edema and pain at site of trivial injury, 
2. massive edema of entire extremity with or following infection, 3* the 
hard edema of the dorsum of the hand after injury. Several theories as to 
the etiology are mentioned including circulatory obstruction, inflammation 
or a combination of the two. Case reports are given of two young Army men 
who suffered trauma to the dorsum of the hand followed by hematomas and 
subsequent hard painful edema and limitation of motion of the fingers. Sur- 
gical excision of dense, fibrous, cartilage-like masses was carried out in 
both cases after conservative measures afforded no relief. Some residual 
pain and limitation resulted, however. No definite conclusions were reached 
as to the cause of the edema. The individual predilection to keloid forma- 
tion was considered and seemed to explain to a point why the picture occurs 
in some injured hands and not in others. The authors feel that the excision 
of the dorsal fibrous mass is the treatment of choice as spontaneous regres- 
sion is not likely. 
Nach and Lohman (21*) report a case of acute arterial insufficiency with 
resultant gangrene of the fingers resulting from thrombosis of the radial 
and ulnar arteries following self-administered codeine injection. Other 
cases of arterial thrombosis following trauma to an extremity as described 
in the literature are mentioned. It is postulated by the authors that the 
trauma of the needle initiated the thrombosis. This is a hitherto unreported 
type of complication occurring in narcotic addicts. 
Non-suppurative tenosynovitis of the tendon sheath of the extensor car- 
pi ulnaris and its clinical picture is presented by Dickson and Luckey (25). 
The patient usually has a twisting wrist injury followed by pain deep in the 
wrist joint and oftentimes swelling about the distal end of the ulna. The 
pain may be aggravated by all wrist motions. Numbness and tingling along 
the dorsal cutaneous ulnar nerve may be present. There is tenderness along 
the course of the tendon as well as grating on motion of it. Edema of the 
surrounding soft tissues was observed in all cases. At operation, at which 
the tendon sheath was incised and not resutured, the sheath was found to be 
thickened and hyperemic. 
Bonnin (26) briefly discusses chemotherapeutic and antibiotic therapy 
in infections in the hand. Purulent tenosynovitis, the anatomy of the ten- 
don sheaths, bursae and spaces of the hand and appropriate incisions for ade- 
quate drainage are described. Sites of election for finger amputations at 
various levels is also presented* 
Reconstruction and Plastic Procedures 
Lelbolt (27) gives a recapitulation of the general principles involving 
reconstruction of the hand by surgery. The general methods of bone repair, 
plastic surgery, procedures to improve joint function, principles of nerve 
and tendon repair and operations to establish opposition of the thumb are 
briefly outlined. Barsky (2d) reports a technique, applicable to certain special cases 
for thumb restoration, by means of finger transplantation and nerve suture 
in stages, Stereognosis can be achieved which flaps taken from distant 
regions cannot do. Other methods in cases of partial, subtotal and total 
loss are also described. Of the nine cases presented only one developed a 
complication, which was ulceration of the distal end of the thumb tube, 
attributed to too early severance of the tube without progressive clamping 
off of the circulation. The use of different type bone grafts is discussed. 
The author expresses his preference for a curved portion of the ilium be- 
cause of more rapid healing. A practical work prosthesis is also demonstra- 
ted in photographs. 
A case report of reconstruction of a new thumb by tubular pedicle and 
bone cartilage graft is presented by Hardin (2y). It was stated that the 
patient has a useful extremity with a thumb for opposition. Evaluation of 
sensation, viability, and motion has been observed over a seven month 
interval• 
Weckesser (30) gives a case report of traumatic amputation of the dis- 
tal portion of a right thumb in which immediate reconstruction was carried 
out by means of abdominal tube pedicle flap followed by iliac bone graft. 
Nieto Cano (31) presents a case report of a patient who lost the distal 
two phalanges of each of four fingers on a hand. Lengthening was performed 
by iliac bone graft and skin replacement with skin from the chest. Except 
for the loss of the bone graft applied to the index finger the results pro- 
duced were satisfactory functionally. Pictures of the end result included 
showing the patient tying his shoelaces, writing, strumming a guitar and 
dealing cards. 
Tanzer and Littler (32) state that a satisfactory reconstruction of the 
thumb should meet three requirements; 1, sufficient forceful flexion and 
extension to permit grasping, 2. opposability of the tip of the reconstructed 
thumb to the pulp of at least one digit, 3. tactile sensation at its tip. 
They present methods for the reconstruction of subtotal or total loss of the 
thumb by transposition of an adjacent digit, meeting the aforementioned re- 
quirements, and report seven cases. In practically all cases, the interven- 
ing defect produced by migrating another digit requires a pedicle flap. 
They state, also that it is preferable to perform the transposition and bony 
fusion in separate stages in order to obtain more accurate positioning of 
the reconstructed thumb. Following fusion, further revisions in the nature 
of tendon transplants, grafts, or tip shortening is frequently necessary. 
Apparently a damaged digit can often be more effectively employed in recon- 
structing a thumb than in attempting to restore its usefulness as a finger. 
According to Gill (33) the first prerequisite for successful reconstruc- 
tion of bone is adequate skin coverage, which may be obtained by primary 
closure or pedicled skin grafts but not by split grafts. The problem of 
residual stiffness is partially solved by practicing atraumatic technique, 
by the use of massive pressure dressings and by the use of internal fixation 
with Kirschner wires instead of plaster casts. Iliac bone is most often 
used as grafts in bridging defects, formation of struts and arthrodesis. 
The metacarpal shift is most useful in most hands with a loss of the long 
or index metacarpal and digit. This procedure eliminates the awkward crossing of the fingers upon flexion. Other types of reconstruction of bone include 
grafts from amputated fingers and arthrodesis of the interphalangeal joints. 
Ruch (3U) discusses three recognized methods of reconstruction of the 
thumb following its loss: 1, Rotation of an adjacent digit into the posi- 
tion of the thumb, 2, Transplantation of a digit from the opposite hand or 
foot, 3. Formation of a new member using a pedicle graft for soft tissue, 
and at some stage implanting a bone graft. The author emphasizes certain 
refinements utilizing the latter technique along with a case report and il- 
lustrations of the various steps in the method. 
Graham and Riordan {35) have used the heads of the Uth and 3th meta- 
tarsals as transplants to restore function of a destroyed metacarpo-phalan- 
geal Joint successfully. Excellent results in five well illustrated cases 
are presented. Emphasis is placed upon: 1. the importance of excising all 
cicatricial tissue from the site to receive the transplant; 2, the reesta- 
blishment of complete intrinsic muscle control of the proximal and distal 
Joints of the finger; and 3. prevention of anterior subluxation by reconstruct- 
ing the extensor mechanism and by splinting the finger in complete extension 
during the period of immobilization. The transplant is fixed in place by 2 
Kirschner wires through the adjacent metacarpals. 
Blake (36) groups thumb injuries and operations into three groups de- 
pending on the degree of tissue loss. I, with a functioning Mp joint re- 
quiring only the removal of painful or adherent scars to give a good oppos- 
ition stump. II, where the MR joint is lost, requiring some form of elong- 
ation to permit a firm grasp and III. where there is total loss of all thumb 
elements complete digit transference or migration of the index finger is 
necessary, A reconstructive procedure in a group II case is described in 
which an abdominal tubed pedicle skin flap was transferred, followed in a 
month by stabilization of the skin thru the insertion of an iliac bone graft. 
Gentle use of the thumb is allowed as soon as there is x-ray evidence of 
union of the bone graft. 
Moore (37) is of the opinion, after clinical appraisal of many war 
injuries to the hands and many types of operations to restore lost prehensile 
activity, that the method of choice in the majority of cases is pollicization. 
Any operative procedure that claims to restore opposition, the author feels, 
should fulfill the following conditions: 1. Prehensile ability must be 
restored, 2. It must be strong so that an adequate grip is obtained, 3, It 
must retain or restore normal sensation in the new thumb. Many methods used 
to restore opposition are discussed. 
Cuthbert (3d) reports a completed case of pollicization of the index 
finger. The'author states that the two prime indications for use of this 
method as opposed to lengthening of the thumb are: 1, Abscence or shortness 
of proximal stump of the thumb, 2, Damage and resultant functionally dis- 
abled index finger. He stresses the importance of maintaining a normal 
nerve and vascular supply and preserving long flexor and extensor tendons. 
The importance of physiotherapy and occupational therapy in the post- 
operative treatment of tendon grafts and tendon transfers in the hand is 
noted by Phalen (39)* The author's description of the various types of ten- 
don transfers should prove useful to physiotherapists who contribute to a functional result, but who may not have had the opportunity of visualizing 
the operative procedures concerned• 
Bruner (Uuj states that the tendons available for transfer to the 
first dorsal interosseus are* the extensor indicis proprius, a flexor dig- 
itorum subliraus and the extensor pollicls brevis. He has used the latter 
successfully and he states that it is particularly indicated in ulnar nerve 
lesions where recovery is doubtful. Its use is not disabling, it has a 
favorable angle of pull, it is long enough to be used without lengthening 
by graft and it is strong enough to restore function. 
Van Demark (Ul) describes the tendon transplantation of Sir Robert Jones 
and Billingion for irreparable radial nerve palsy. For three weeks postoper- 
atively the hand is immobilized in a plaster splint with the wrist dorsi- 
flexed, fingers extended and the thumb extended and abducted. Mobilization 
is begun thereafter. 
Kirklin and Thomas (U2) evaluate 75 cases of tendon transplants to 
regain thumb opposition. Essentially 6 basic methods are described and eval- 
uated by table as to excellent, satisfactory and unsatisfactory results. 
Apparently all of the methods are capable of giving good results under var- 
ious circumstances and careful evaluation of the function of the entire hand. 
Their method of choice under permitting circumstances was the use of the 
flexor digitorum sublimus of the fourth finger transplanted with direct in- 
sertion into the thumb on its lateral side at the base of the proximal pha- 
lanx after having wrapped it around the flexor carpi ulnaris tendon near 
the latter insertion. 
Pulvertaft (U3) gives a brief and concise review of the physiology of 
tendon repair, principles of treatment and general technique of operative 
repair, A discourse on tenolysis is also presented together with an analy- 
sis of 130 examples of tendon repair and tenolysis operations in an attempt 
to evaluate results. 
Burman (uU) discusses in detail the kinetics of the normal thumb, and 
its kinetic disturbances. He states that the neutral position of the wrist 
gives best use of the fingers and thumb. The advantages of transplanting 
the extensor carpi 'ulnaris to give abduction of the thumb for various con- 
ditions are propounded and recommended as »one of the standard tendon trans- 
fers1, The operative procedure is described in detail together with case 
reports with pictures. 
Stack (U5) states in a brief paper that 7 patients, having been followed 
for a period from 10-13 years, who have had excision of both the carpal 
scaphoid and lunate presented most favorable results from the standpoint of 
strength, alignment and range of motion of the wrist. This "can be expected 
if the two bones are removed as primary treatment following fracture and 
dislocation". He further states that where minor arthritic changes have de- 
veloped the limitation of motion will probably not be overcome but reasonable 
assurance can be given that pain will be relieved and further change will not 
take place. 
The commonly observed pronounced degenerative arthritic changes about 
the radial styloid in old cases of non-union of the carpal navicular provides a case for discussion by Barnard and Stubbins (U6) • Other aspects of the 
role of the radial styloicl are discussed in this type of surgery* The auth- 
ors excised the radial styloid in 1U cases and in 7 cases utilized the frag- 
ment, largely cancellous, for bone grafting. They stated that 9 out of lo 
cases had good end results although the follow up period was only two and 
one-half years. 
Butler (U7) reports fusion of the radio-carpal, intercarpal and meta- 
carpal joints of the wrist by means of a curved graft from the inner surface 
of the wing of the ilium. The graft is fan shaped, and its natural curve 
permitted fixation of the wrist in the optimum position of ten degrees of 
dorsiflexion; it was applied to a deep bed cut in the radius, carpus and 
second to fifth metacarpals. The operation is suitable for osteoarthritis; 
infective, tuberculous and rheumatoid arthritis; infantile spastic and trau- 
matic paralysis and congenital deformities. The advantages are the more 
rapid union than with tibial grafts, and the more certain union than with 
iliac chip grafts. Thirty patients, two with tuberculosis of the wrist, 
were successfully arthrodesed, one necessitating a second operation by rea- 
son of fracture of the graft. 
Bazliel (U8) modifies the Brittain wrist arthrodesis by cutting an 
angled graft from the antero-medial aspect of the tibia with an angle of 
1U0° between the connecting arms. In this way when the graft is incorporated 
in situ the position of function of the wrist can be achieved without dif- 
ficulty and the graft is "imbedded” in place throughout its entire length. 
According to Bunnell and Howard (U9) a Kirschner wire drilled through 
the ulna and radius just above the wrist effectively prevents all pronation 
and supination. Incorporating the wire in a forearm cast eliminates the cus- 
tomary long arm cast for preventing pronation and supination. 
May (50) discusses the consequences of improper immobilization of the 
hand, leading to contractures after injuries, infections and bums. Ke out- 
lines the repair work of these contractures and also the treatment, by sur- 
gery, of Dupuytren's contractures of the palmar aponeurosis after the method 
of Lexer (5l). 
Despite the frequence of congenital syndactyly and the many repairs 
devised, after many of the operations in common use either the web creeps 
distalwards or the range of extension of the affected fingers is defective, 
Oldfield (52) feels that secondary deformities are due to scar lines which 
are allowed to develop along the base of the web. Therefore, it would seem 
that an operation planned with the view of lining the whole base of the web 
with a single flap of mobile skin would be the operation of choice. Such an 
operation is described with a single «Uf flap or 'horseshoe' being raised 
dorsally to fill the base of the web. Lateral digital flaps from the remain- 
ing skin are fashioned so as to cover the side of the more important finger 
(usually the index) and the resulting defects on the other fingers are cov- 
ered with split thickness skin grafts. The author feels that 2 years is the 
ideal age for operation but that each case must be individualized. Re cau- 
tions against operation in adults who have adjusted finger function to the 
webbing. 
Douglas (53) describes an operation to aid in formation of new nail 
beds. It consists essentially of making a double pedicle flap and shifting it from the distal end of the finger involved proximally over an artificial 
nail collodionized to the nail bed. He used the procedure successfully in 
one case. The pedicle was excised after the new growing nail reaches well 
out of the finger tip (approximately 5 weeks). He deduces that the proced- 
ure may be applied to the problem of split nails. 
Armstrong (5U) gives details of a technique for arthroplasty used in 
soldiers with ankylosis of the elbow due to shell wounds. Through two long- 
itudinal incisions, one on each side of the triceps tendon, the head and 
neck of the radius were removed and the humeral and ulnar elements of the 
ankylosed joint freed. Sufficient bone was removed from the humerus to make 
the surface flush with the flat area just above the condyles; the concave 
surface of the ulna was enlarged with a g ouge, care being taken to preserve 
the insertions of the brachialis and triceps. The sac of a hydrocoele was 
drawn like a cap over the lower end of the humerus. Graduated movements 
were begun fourteen days after operation. Mr. Armstrong was impressed with 
the stability of the new joint thus constructed, as compared with that of 
other techniques; 60 percent of normal flexion, extension and rotation were 
regained without pain. 
Willner (55) describes an operation through two incisions, one on the 
medial aspect and one on the lateral aspect of the elbow to release a fibro- 
tic anterior capsule of the elbow affecting a flexion contracture. It is 
to be understood, however, that all flexion contractures of the elbow are 
not necessarily caused by anterior capsular pathology. Ten case reports are 
included with an increase in range of elbow motion from 3u-h5 degrees (ten 
degrees of flexion and twenty-five degrees of extension). Fost operatively 
the compression dressing is not disturbed for three days and active exercises 
started on the fourth day. Forceful extension by weight or trapeze are for- 
bidden, Follow ups have been of short duration. 
Rank and Wakefield (56) present a method for elongation of the thumb 
wherethe metacarpal is functioning. The procedure is of four stages: 1. 
The raising of the tube pedicle, 2. Attachment of the pedicle to the hand. 
3. Detachment of the pedicle from the abdomen and U. The bone graft. The 
tribulations of each step are presented as are lb case reports in a tabulated 
table form. Appropriate pictures are included, plus a mention of lengthening 
of digits other than the thumb, to facilitate opposition. 
Schroder (57) discusses the various tendons available for transplanta- 
tion for the various nerve palsies of the forearm and hand in accordance 
with the principles propounded by Bunnell. The remedial treatment following 
surgery and the advantages of various types of occupational therapy in ad- 
dition to physical therapy are discussed. 
Gervis (5b) briefly discusses the etiology of simple osteoarthritis of 
the trapezio-metacarpal joint and describes the not unusual physical findings 
of the lesion. He discusses excision of the trapezium in thirteen patients 
and although it leaves the function of the thumb slightly weaker than normal, 
a full range of motion is regained. Supervised physiotherapy is essential, 
since due to pain, the patients subconsciously tend to splint the joint. He 
prefers this procedure to arthrodesis. Miscellaneous 
Although not previously unrecognized, cyst like lesions of the carpal 
bones have received little attention in the literature. Rodholm and Phemis- 
ter (59) point out the resemblance of the cyst like areas in the carpal 
bones to the cysts of the capital femoral epiphysis and have assumed that 
their pathogenesis is essentially the same. Such lesions are not unlike 
those seen in the hip in degenerative arthritis. Aseptic necrosis of one 
or a part of a carpal bone has been described in association with such le- 
sions. These changes are said to be not uncommon. 
Nygaard (60) summarizes ”a report of a patient who exhibited a non-uni- 
ted fracture of the carpal navicular bone of twenty-two years duration, as- 
sociated with intermittent Raynaud*s phenomenon of the corresponding hand. 
Functional restoration of the hand followed operative removal of the project- 
ing movable fragment**. Preoperatively, the Raynaud*s phenomenon could be 
reproduced by weight carrying but not by exposure to cold. Similarly it 
could be prevented by local infiltration of novocaine around the loose frag- 
ment. 
Vaughan-Jackson (61) presents two case reports of rupture of the ex- 
tens or‘Ten3EEs~olT'tHe fingers by attrition at an arthritic inferior radio- 
ulnar joint. At operation the mechanism could apparently be reproduced. 
When the forearm was pronated and supinated an arthritic roughening of the 
articular margin of the lower end of the ulna could be seen moving to and 
fro in a hole in the groove for the tendons and thru which the arthritic 
lipping could project to impinge on the tendons themselves. Treatment con- 
sisted of excision of the distal three centimeters of the ulna and tendon 
grafting, using *split tendon* grafts, with almost complete return of func- 
tion and no residual disability. 
Lahz (62) states that tennis elbow can be due to direct trauma as well 
as indirect muscular violence and that the muscle origins mainly concerned 
are the extensor carpi radialis brevis, the extensor digitorum communis, 
and the supinator muscle. The theoiy of an incomplete muscle tear is un- 
supported by histological evidence. He believed that the cause of the pain 
is a localized synovial reaction. The acute stage often passes to chronic 
synovial inflammation with secondary involvement of the capsule, muscle, 
and rarely periosteum. In the acute stage plaster fixation is advisable 
with the elbow flexed and the wrist dorsiflexed. Manipulation is worth try- 
ing in chronic cases but operation offers an almost certain cure. The ori- 
gins of the extensor carpi radialis brevis and the finger extensors should 
be divided obliquely and the radio-capitular joint explored for thickened 
synovial fringes. 
Schulenburg (63) describes the normal movements of the thumb and the 
effects of procaine block on the thenar muscle. He reviews some of the lit- 
erature pertinent to anomalous nerve supply and offers convincing evidence 
that the flexor pollicus brevis is frequently supolied by the ulnar nerve. 
Stress is laid on the correct interpretation of movements of the thumb in 
assessing a case of nerve injury. 
Gouldlng (6J+) presents a case report of a 22 year old engineer who under- 
went two exploratory operations for a painful swelling just proximal to the wrist joint on the volar aspect. Five years later pain and swelling returned 
and reoperation revealed the muscle belly of the palmaris longus to be gross- 
ly hypertrophied, reaching almost to its insertion. The major portion of 
the muscle was excised. No follow up report was made. A general discussion 
of the anatomical variabilities was presented with the conclusion that the 
degree of development attained is in accordance with function. Similarly it 
was considered that the muscle is gradually passing into phylogenetic decrep- 
itude in man. 
Cliffton (65) reports several cases with residual function of the in- 
trinsic hand muscles despite confirmed complete severance of their nerve sup- 
ply. Communications between the median and ulnar, and median and musculo- 
cutaneous nerves via anatomic pathways are described. Granted such cases 
are unusual, they are of importance in evaluating peripheral nerve injury pre 
and post operatively. 
Bateman (66) presents a method of denervating the elbow joint, based on 
a study of the innervation of 152 elbow joints from the median, radial, ulnar 
and musculocutaneous nerves. The technique, stressing extensive stripping of 
the various nerve trunks through three incisions about the joint, is described. 
Summaries of eleven cases are included. In those with post traumatic and 
osteoarthritis, there was relief of pain and painless, but not increased, mo- 
tion. One patient with acute rheumatoid arthritis redeveloped pain after 
six months. The longest follow up period was 21 months. No complications 
were noted. 
Doyle (6?) gives case presentations of some of the more common types of 
syndromes in which r adicular pain in the upper extremity is a predominating 
feature. The author summarizes! "radicular pain in the upper limb has the 
same general characteristics it exhibits elsewhere. It is limited to the 
area of distribution of a sensory nerve root, is generally aggravated by 
coughing and straining, and by reclining for long periods, and is frequently 
relieved by assuming the upright position. If severe or persistent it may 
be accompanied by muscular weakness with atrophy and fibrillations due to 
degeneration of the fibers of the corresponding motor root." 
Haggert and Winter (68) discuss the anatomy, pathology, clinical course 
and treatment of DeQuervain’s disease. They recommend operative treatment 
and condemn radiation therapy because the latter fails to give relief and 
results in fibrosis and scarring, making the surgery more difficult. Post- 
operatively, active thumb exercises are commenced after 2k hours. 
In a discussion of Dupuytren*s contracture, Gordon (6y) concludes: 
"Dupuytren1 s contracture is a fairly common lesion of the hands and is oc- 
casionally seen in the feet. Its etiology is unknown* its pathology ques- 
tionable, It is commonest in males, and develops most frequently between 
the ages of UO and 60. When first seen clinically, both hands are involved 
in a majority of instances; if only one hand is involved, it is usually the 
right. Finger involvement occurs in the lith, 5th, 3rd and 2nd and thumb, 
in that order, the Uth being involved ten times more frequently than the 2nd. 
The only satisfactory treatment is the excision of the palmar fascia, to- 
gether with any hopelessly involved skin. Skin replacement can be done satis- 
factorily with a thick dermatbme graft. A good result may be expected in 85$ 
of the cases." These conclusions are based on experiences with luO cases of 
the condition plus a review of the literature. Hammond and Potter (70) present a case of Dupuytren's contracture of 
the palms of both hands and soles of both feet. The left hand was operated 
and revealed the characteristic connective tissue hyperplasia without evi- 
dence of inflammatory reaction. They state they believe the incidence of 
the condition in the feet would probably be much greater if examination were 
carried out on those patients presenting themselves with the hand involved. 
Specimens were not procured from the feet of the patient presented. 
Fauteux and Ripstein (71) state that the etiological relationship be- 
tween Dupuytren's contracture and coronary heart disease is not established 
but the possibility of the contracture being due to irritation of the sym- 
pathetic nervous system must be considered. Two cases of the contracture 
are presented which followed coronary occlusion. 
Stecher and Hauser (72) present a study of the gross and roentgenograph- 
ic appearance of Heberden's nodes because they are typical examples of de- 
generative joint disease. They emphasize the value of photographs and later- 
al roentgenograms in describing and following the progress of these lesions. 
The development of large spurs at the attachments of the flexor and extensor 
tendons to the terminal phalanges and the ”foamy arrangement of the trabeculae” 
in the distal ends of the middle phalanges are characteristic. Heberden's 
nodes were associated with degenerative joint disease of the proximal inter- 
phalangeal joints in h0% of their cases. conclude that degenerative 
joint disease involves periarticular soft tissue, tendinous attachments and 
subchondral joint spaces as well as the joint cartilage and the immediately 
underlying bone. 
Newman (73) describes the anatomy of the carpal tunnel, emphasizing the 
fact that it is a closed space of bone covered with a roof made up of the 
transverse carpal ligament* He conjectures that the nerve is involved first 
during diminution of this space because the nerve lacks the protective coat 
of the tendons, namely, their tendon sheaths. The effect of pressure is one 
of ischemia rather than direct irritation. Three 'types* are presented: 1. 
Due to acute trauma. 2. slew compression with spontaneous onset, and 3* 
slow compression secondary to malunion or arthritis. The symptoms and signs 
are outlined. He presents three cases, each treated by incision of the 
transverse carpal ligament with complete relief* BIBLIOGRAPHY 
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M. J., 2h: 26U-269, May 19U8 SECTION 18 
AMPUTATIONS AND PROSTHESES 
Prepared by August W. Spittler, Colonel, M. C., U. S. A. 
and Resident Staff 
Amputations 
Chamley (1), in discussing amputation for the benefit of the general 
practitioner, presented the principles which govern the diagnosis of the 
ideal stump5 the principles underlying the technique of emergency amputa- 
tions, and the domiciliary supervision of the recent stump. 
The Design of the Ideal Stump: In the arm and forearm preservation 
of maximum length is of paramount importance. The author is against the old 
dictum contraindicating amputation through the proximal interphalangeal 
joints, as many fingers so amputated have had powerful flexion afterwards. 
In the case of an index finger, a careful amputation through the shaft of 
the metacarpal gives a good cosmetic result. In the lower extremity, only 
two stumps are recognized as ideal; below knee amputations containing four 
to five inches of tibia, and above knee amputations contained from nine to 
twelve inches of femur. It is recommended that the bone end be covered 
only with skin and deep fascia; that the nerves be sectioned at the level 
of the muscles and that they are not drawn down, crushed, injected with 
alcohol, or tied with ligatures. Though these principles are those which 
underlie the present teaching in the amputation of election, it must not 
be forgotten that there are many unorthodox amputations still functioning 
or which have functioned well for years. A Symefs amputation is preferable 
on a young man rather than an immediate below knee amputation, although 
suitable cases are rare. (Ed. note; It is believed that more cases can 
be found suitable for Syme!s amputation particularly if done in two 
stages for infected foot and ankle wounds.) Many patients have been seen 
with an amputation through the forefoot (Lisfranc) who are able to walk 
well in an ordinary shoe, after filling the toe with cork. Between the 
Syme*s and Lisfranc!s, however, nothing should be attempted; experience 
has shown that the Chopartfs amputation is not a good amputation. 
Two Primary Objects in Emergency Amputation: One is to aim for the 
longest possible primary stump, and two is to plan the amputation with 
flaps for delayed closure. A guillotine operation should never be per- 
formed by sectioning the bone and soft parts at the same level, because 
healing is slow, the patient is miserable, and elective amputation will 
generally have to be risked in the presence of an unhealed terminal ulcer. 
In aiming for a generous length of primary stump, the bone should always 
be divided at a higher level than the skin in order that flaps can be 
fashioned of sufficient length to cover the bone end. In all emergency 
amputations the wound should be regarded as more or less heavily inocu- 
lated with bacteria. Delayed closure of the amputation stump with the 
use of dry gauze packs, which are removed under aseptic precautions' not 
}Ater than the fifth postoperative day, gives a good result in the authorfs 
hands• 
3^ Care of the Stump: While awaiting the fitting of a stump two ob- 
jectives must be attained; one the shrinkage of the stump into a conical 
shape, and two, the prevention of flexion contracture in the joint proxi- 
mal to the amputation. The conical stump is achieved by careful bandag- 
ing which is done by the patient or a relative who has been properly in- 
structed how to reapply the bandage morning and evening. The flexion 
contracture of the joint proximal to the level of amputation can be pre- 
vented by regular exercises to strengthen the muscles. In finger ampu- 
tations the use of other digits is of great importance. Bandages must be 
discarded as soon as possible to expose the stump to the air, and to per- 
mit the use of the fingers actively. 
Illingworth (2) reviews the subject of amputations, listing indica- 
tions, and gives a good discussion of the technique used for each site. 
The description of prostheses is brief. 
Blair and Morris (3) in a study of 2,612 patients with 2,76? major 
amputations give a resume' of technique, preferred levels, precautions 
and prostheses as used on an orthopaedic service at one of the Army1 s 
amputation centers. 
Swenson and Bisgard (1|) discuss various levels of amputation and the 
most suitable prosthesis for each. They deplore the lack of coordination 
between the surgeon, physiotherapist and limb fitter. 
Maxeiner (5) reports the results of the use of tourniquet amputation 
in 20 cases. He suggests its use as an expedient to be used in those 
cases in which an extremity must be sacrificed but in which a classical 
amputation would be extremely hazardous. The tourniquet may be used for 
a few days only at which time a classical operation may be done if the 
improvement in the patient's physical state warrants, or it may be allowed 
to remain on until a guillotine amputation has been accomplished except 
for the insensitive compressed tissue and bone. The author gives as in- 
dications for the life-saving procedure as follows: (1) Severe trauma 
with irreparable damage to an extremity of a patient who is suffering 
severe shock from loss of blood or the magnitudes of his injury; (2) 
Virulent infections, especially gas gangrene; (3) Gangrene due to disease, 
or concomitant diabetes or concomitant critical heart disease. The rub- 
ber tubing is tightly stretched and wrapped about the selected site, each 
turn of the tubing overlaps the one below so that the constricted area is 
as narrow as possible. The extremity distal to the tourniquet is next 
wrapped with a goodly quantity of white cotton, saturated with formaldehyde 
solution and enclosed in a rubber sheet. In 8 to 10 days a groove through 
all the soft tissue to the bone is made, at which time a Gigli wire saw 
may be placed in this groove immediately above the tourniquet and the 
remaining tissue and bone cut across without anesthesia. The author's 
report of statistics on the 20 cases showed that there were 6 deaths or 
a mortality of 30$, none of which could be attributed to the method. 
Altavas (6) reports a case of auto-amputation of the thigh in a case 
of gangrene, following a compound fracture of the femur. Healing was com- 
pleted by secondary intention and no surgery. 
Alldredge (7) presented an excellent report on cineplastic amputa- 
tions with additional knowledge of the cineplastic method gained from observations by the Army Surgeon General*s European Commission on Amputa- 
tions and Prostheses in 19U6, and the work of the Committee on Artificial 
Limbs since that time. In Germany the cineplastic method still in use is 
that of Sauerbruch, developed during and after World War I. The method 
was found to be in active use in two centers, Munich and Berlin. In these 
centers cineplastic methods were not used to the exclusion of other methods. 
Patients were usually given their choice of the three methods generally 
used - the cineplastic, the Krukenberg, and the conventional methods re- 
quiring no surgical procedures. 
Sauerbruch in Berlin has continued to use the conventional cineplastic 
method. Lebsche of Munich has introduced a modification which seems to 
improve the results without unduly complicating the procedure. He intro- 
duced the practice of liberating the distal attachments of the canalized 
muscle in cineplastic operations. It was the author*s observation that 
this produced more excursion and strength of the muscle, and was better 
controlled by the patient. 
r’The principle of the method consists in the use of two muscle motors 
on the arm; these are constructed by raising a flap of skin on the stump 
and converting it into a tube, which is placed through a hole in the muscle 
belly. When the muscle is contracted by the amputee, the tube is moved. 
A rod through the tube is connected to the prosthesis. Active contraction 
of the muscle thus governs the action of the prosthesis through the rod. 
One muscle motor is constructed on the flexor surface of the arm and the 
other on the extensor surface. The selection of the sites for placement 
of the muscle motors is of the utmost importance. The muscles should be 
tunneled at the distal end of the muscle fibers. The excursion of the 
muscle tunnel is in direct proportion to the width or diameter of the 
muscle belly. The biceps alone or the biceps and triceps should both be 
canalized for short stumps below the elbow, and the pectoral motor should 
be used for short arm stumps above the elbow. The preoperative and post- 
operative care, consisting chiefly in proper muscle exercise, is highly 
important. Before operation, all of the muscles are strengthened to the 
maximum extent, and the patient is taught selective use of those to be 
tunneled. Following operation, the patient is taught active use of the 
muscle motors, while the muscles are stretched to their full length. 
Strength and excursion of the motors are increased by active contraction 
of the muscle motor against gradually increasing resistance on a rod 
which passes through the tunnel.1' 
The author found the German cineplastic prosthesis was essentially 
the same as that originally developed. It lacked many desirable cosmetic, 
functional, and mechanical features. It is also very delicate, and the 
component parts are subject to wear and frequent breakage. When a better 
prosthesis has been made available, the method may well enjoy more ex- 
tended use than at present. The results of studies on this subject at 
the University of California have indicated a definite need for compensa- 
tory mechanisms in the prosthesis, to take the place of the natural one 
which were lost when amputation was sustained. 
(Ed. notes Prostheses are now available to make the biceps tunnel 
an excellent motor for the below elbow amputees. Flexor and extensor tunnels are not necessary and in the forearm are not proving to be of too 
much use. The pectoral tunnel is excellent but still needs some study to 
apply its power adequately.) 
Craft (8) discusses Krukenberg and cineplastic operations. He favors 
the Krukenberg operation because of the retention of tactile sensation but 
did not like its appearance. In his discussion of the cineplastic motors 
he felt that the main drawback was the fitting with proper prostheses. He 
discussed the advantages of relieving the distal end of the truncated mus- 
cles and a large diameter tunnel. 
Millar (9) gives a case report of a traumatic forequarter amputation 
which was closed primarily after shock therapy and had healing in Hi days. 
Vasko (10) gives a case report on an almost complete subcutaneous 
traumatic amputation of thigh which was saved by adequate surgery on bone 
and muscle, (Ed. notes With retention of adequate blood supply and soft 
parts for coverage transversely severed muscles should respond to repair.) 
Wise (11) devised a method of control of the common iliac artery in 
sacro-iliac disarticulation. Early in the operation he places a tape 
through a section of soft rubber tubing, clamping the tube with a hemostat. 
After all branches are ligated, the tape is removed. 
Van Nes (12) reports the replacement of a totally resected femur with 
a "turn-up plasty” of the leg to replace the femur with tibia and fibula. 
The patella is left at the end to bear the weight as in a Gritti-Stokes 
amputation. 
Phantom Limbs 
Browder and Gallagher (13) studied 150 amputees for all types of con- 
ditions', All adults had some degree of phantom limb for a variable period; 
33$ suffer with pain either in the stump or phantom limb, 75$ of these 
slowly lose it. No phantom limb was noted in the congenital absence of a 
limb. The lower extremity amputee has less striking phantom sensation and 
is most likely to lose it spontaneously. In cases when the 11 ghost” was 
distorted or cramped there was intractable pain for which the authors ad- 
vocate cordotomy. They have improved 6 cases with the operation. 
Bingham (1U) (15) feels that sympathectomy is treatment of choice 
following the use of procaine blocks to evaluate its efficacy. He does 
not believe that character of sensation is any differential point as to 
cause or treatment. 
Craig (16) uses a local injection of 1$ novocaine into the sympathetic 
nerve supply repeating it indefinitely and believes the remission will 
eventually become sufficiently long to avoid more extensive surgery. 
Carlton (1?) believes the blocking of afferent impulses at the level 
of the thalamus causes overreaction resulting in phantom pain. He feels 
overstimulation of the stump will overcome this and advocates firm manipu- 
lation, beating of stump with hand and mallet# Prostheses 
Brashear (16) by questionnaire tried to evaluate the value of arti- 
ficial appliances in upper arm prostheses. He received answers from 55 
who used them. Only a shoulder disarticulation case did not use one. 
The average cost was $300 to $350. 
Henschke and Mauch (19) describe an improved leg prosthesis with con- 
trol of knee by voluntary and involuntary fixation to prevent falling with 
abdominal muscle control of a hydraulic-mechanical system. The ankle al- 
lows movements in pronation and supination also. (Ed. note: This has 
been further improved to provide the control within the leg itself.) 
Kessler (20) discusses a utility attachment for cineplastic artificial 
arms, to provide prehension without crushing objects. 
Strickland (21) describes a pneumatic artificial footf Fahlstrom (22) 
and Markkula (23), a knee joint; Eberle and Hansen (2ii), a hydraulically 
operated limb; Snethan (25)* an artificial hand and arm; Hinkle and Weger 
(26), a knee lock for artificial legs; Havens (27), a linkage for artifi- 
cial legs and Tureman (28), an artificial hand. BIBLIOGRAPHY 
1. Charnley, J.s Amputations, Practitioner, 160: 206-211, Mar. 191$ 
2. Illingworth, C. F. W.s Textbook of surgical treatment including op- 
erative surgery, 3rd edition, Edinburgh, Livingstone, 66-82, 19U7 
3. Blair, H. C. and Morris, H. D.s Amputations, West. J. Sung., 56: 
105-109, Feb. 19i$ 
U. Swenson, S. A. and Bisgard, J. W.: Amputation of extremities. Am. J, 
Surg., ?6: 610-618, Nov. 191$ 
5. Maxeiner, S. R. s Tourniquet amputation#. Internet• Coll. Surgeons, 
11: 171-177, Mar-Apr. 191$ 
6. Altavas, Rs Spontaneous auto-amputation of thigh in case of gangrene, 
(case report), Philippine J. Surg., 2: 113, May-June 19U7 
7. Alldredge, R. H.: Cineplastic method of upper extremity amputation, 
J. Bone & Joint Surg., 3QA: 359-373, Apr. 191$ 
8. Craft, A. W. J.; Cineplastic and Krukenberg Operations, Guy's Hosp. 
Gaz., 61s 322-328, Nov. 22, 19U7 
9* Millar, J. D. C.: Instantaneous traumatic forequarter-amputation of 
the right am, Brit. M. J., 2: 559, Sept. 18, 191$ 
10. Vasko, J. R.: Subcutaneous, subtotal, traumatic amputation of thigh, 
Am. J. Surg., 76; 328-331, $£pt. 191$ 
11. Wise, R. A.: Control of common iliac artery during sacro-iliac dis- 
articulation, Ann. Surg., 128: 993-993, Nov. 191$ 
12. Van Nes, C. P.; Transplantation of tibia and fibula to replace femur 
following resection ("turn-up-plasty" of leg), J. Bone & Joint Surg., 
30A: 85U-858, Oct. 191$ 
13• Browder, J. and Gallagher, J.: Dorsal cordotomy for painful phantom 
limb, Ann. Surg., 128; U56-U69, Sept. 19i$ 
]$. Bingham, J, A. W.s Pain in phantom limbs (discussion in correspondence 
section), Brit. M. J., 2: 5l, July 3, 19l$ 
15* Bingham, J. A. W,: Pain in phantom limbs, Brit. M. J., 2| 353, Aug. 
Ik, 19l$ 
16. Craig, J. D.; Pain in phantom limbs (discussion in ansmer to corres- 
pondence query), Brit. M. J., Is 90U, May 8, 191$ 17. Carlton, H. H.t Pain in phantom limbs (discussion in correspondence 
section), Brit. M. J., 1: 10£2, May 29, 19U8 
18• Brashear, C. E.s Value of artificial appliances in upper arm amputa- 
tions, Jour. Rehabil., U;: 21-2U, Feb. 19U8 
19. Henschke, U. K. and Mauch, H. A.: Improvement of leg prostheses. 
Mil. Surgeon, 103; 13£-11;6, Aug. 191$ 
20. Kessler, H. H.s Utility attachment for cineplastic artificial arms, 
J. Bone k Joint Surg., 30As 236, Jan. 19U8 
21. Strickland, E. L.s Pneumatic artificial foot. Jour. U. S. Patent Off., 
l£; July 16, 19U8 
22. Fahlstrom, 0. I.; Knee joint for prostheses. Jour. U. S. Patent Off., 
l£: li£2-Ui;6, Dec. 10, 19U8 
23. Markkula, R. F.; Artificial knee joint. Jour. U. S. Patent Off., lUs 
1433-571, 19U7 
21;. Eberle, F. S. and Hansen, H.s Hydraulically operated artificial body 
member. Jour. U. S. Patent Off., l£; (2), 19i;8 
2£. Snethan, H. J.; Artificial hand and arm. Jour. U. S. Patent Off., 
1£; (l£), I9I48 
26. Hinkle, G. A. and Weger, A. T.; Knee lock for artificial legs, Jour. 
U. S. Pat. Off., l£; (l£), 19i;8 
27. Havens, G. G.s Linkage for artificial legs. Jour. U. S. Pat. Off., 
l£: (1U), 19148 
28. Tureman, G. R., Jr.: Artificial hand. Jour. U. S. Pat. Off., 11;: 
(9), 19U8 
3?o: SECTION 19 
NEW DEVICES, APPARATUS AND PROCEDURES 
Prepared by W. Hunter Vaughan, Lt. Colonel, M. G., U. S. A, 
Assisted by William F* MacDonald, Captain, M. C., A. U. S. 
Peter J* Ferrato, Captain, M. C,, A. U. S., and 
James D. Caskie, Captain, M, C., A. U. S. 
Introduction 
As in past years, literature covering new procedures and appliances 
developed and reported during the year 19U8 contains a number of ideas and 
gadgets which are usually modifications of previously used methods with 
their inventors' or authors' recommendations for use because of containing 
some allegedly improved technique which produces better results or which 
simplifies methods already in use. At times some of the recommended devel 
opments appear to complicate already established procedures, and only time 
and repeated application of the new principles recommended will establish 
their general value to the orthopedic and surgical profession. 
Devices 
A new dermatome was patented in 19h8 by Hood (1) and the specifica- 
tions and illustrations indicate that this dermatome is a modification 
of the Padgett dermatome. The author claims that this dermatome provides 
greater visibility during the operation and simple, easily manipulated 
parts, reducing the necessity of making adjustments excepting to set to 
the thickness of the graft desired. Further, he states that this instru- 
ment involves elements for maintaining the severing edge of the cutting 
blade in a given position. The specific objects of this new dermatome 
comprise a provision of normal, unique and positive blade-holding struc- 
ture which prevents the sharpened edge of the blade from ever coming into 
contact with the surface of the graft holder. 
Wydro (2) has patented a dentist's and surgeon's saw particularly 
for use in the mouth which can be attached to an ordinary dental power 
machine. The inventor claims this saw to be a definite improvement in 
removing teeth and operating upon the jawbone or in similar cramped 
spaces. It consists of the principle of having two reciprocating blades 
so arranged that the cutting action is continuous and is always in a po- 
sition for cutting. 
(Ed. note: This saw is simple and compact in construction and can 
be attached to a modern dental power device.) 
Carroll (3) developed a bone cutting saw for larger bones which uti- 
lizes the principle of an oscillating saw blade, which is adjustable for rig£it angle, oblique and longitudinal cuts, and has the advantage of 
steadying the object tb be operated upon by featuring a saw guard having 
spaced arms adapted partially to embrace and steady the bone* This new 
saw includes another feature which allows the blade to yield to the em- 
braced bone* The blade of the saw is driven by a flexible cable which 
is connected to a crank disc, which in turn is operated by a prime mover* 
(Ed* notes The saw is small and easily maneuverable, is held by pis- 
tol grip and does not contain the power unit in the saw assembly head*) 
Gunther and Keyes (U) report a simplified depth gauge for bone sur- 
gery* It is similar to the one in common use except for the set screw, 
which is always awkward. A curved spring slide without set screw is 
used and there is a ring in the end of the wire instead of a heavy handle* 
For two years Curry (£) has used a hip nail counterbore with diameter 
of the Smith-Petersen nail* This opens the dense cortex of the femur to 
allow the nail to enter without fracturing the sometimes already comminuted 
bone. This device was used in £0 cases. 
Herz, Breck and 3asom (6) have designed another type of lock screw for 
securing an intertrochanteric plate to a Smith-Petersen nail* The modi- 
fication described, combined with the lock screw, places greater emphasis 
on security and, the authors further state, "without adding to the diffi- 
culty of application"* Essentially, the improvement consists of the use 
of a left-handed small screw inserted into the l/i*" - 20 screw already in 
use by many surgeons. This develops a locking mechanism for the plate so 
attached to the nail and thereby overcomes a possible complication of sep- 
aration of nail and plate after its use* 
A new laminectomy retractor is described by Reed and Kirgis (7) which 
is of simple construction, consisting of a brass frame which accepts re- 
tractor blades of varying depth as required by the thickness of the para- 
vertebral musculature. The device is made self-retaining by a spring- 
steel locking device which prevents closure of the telescoping sides of 
the frame. The solid bars of the frame have £ holes reamed to allow that 
number of insertions of the retractor blades, so that they may be applied 
at the points where greatest retraction is needed. The device is equally 
useful for unilateral or bilateral exposure. 
Two semilunar cartilage knives are presented by Downing (8) as an aid 
in removing these structures. The description of the knives, one curved 
to remove the posterior half of the attachment of the menisci to the tibia 
and synovia and the other a straight, long-handled knife with a strong 
blade to sever the posterior attachment with or without displacement into 
the intercondylar notch, appear to be an improvement over some knives al- 
ready devised. 
Stein (9) describes a tungsten steel gouge for use in a Nicola opera- 
tion. This improved gouge, he feels, materially helps in drilling the 
hole from below the bicipital groove to the center of the head of the hu- 
merus. The gouge is similar to the one used by Nicola except that it has 
a serrated opening or eye, proximal to its point, which is made by making 
multiple drill holes adjacent to each other and tapering in their diameter toward the polxTb. As the hole is completed the point of the gouge goes 
into the acromium above, and the proximal end of the cut biceps tendon 
is threaded through the new hole in the humerus and the gouge withdrawn. 
The eye of the gouge is thick to prevent cutting of the tendon and tapers 
toward the point better to engage the tendinous tissue, insuring security 
as the gouge is withdrawn. The gouge measures lA" in diameter. 
Another ’’well-leg" type of traction apparatus was developed by Hen- 
derson (10X primrily providing an improved traction splint, using the 
sound leg as an anchor, embodying a comfortable construction device for 
the well leg, and allowing limited movement of the well leg. By means 
of a bone pin through the lower tibia, or os calcis, traction is applied 
to the injured lower extremity in an adjustable manner by two cross 
bars. The author claims increased maneuverability by the application and 
use of this method of traction, as compared to the use of plaster casts. 
The author claims advantage over the present methods of well-leg traction 
due to absence of plaster cast and ability to bathe and cleanse the injured 
part. 
The Roger Anderson Well-Leg and Well-Hip Traction devices, designed 
and first reported in 1931, are described in detail by Miller (11). 
Raney and Raney (12) report a minor modification of the Crutchfield 
tongs by adding a flange sleeve to rest against the outer cortex of the 
skull and also to increase the size and reduce the sharpness of the point, 
as compared to the standard tong. 
(Ed. note: The advantages claimed seem quite Justified and should 
aid in eliminating the occasional complications seen in the use of the 
standard Crutchfield tong for head traction over a prolonged period of 
time•) 
Fulcher (13) reviews the various types of apparatus which have been 
introduced to apply skeletal traction to the cervical spine. He recom- 
mends an improvement over the Crutchfield tongs. The apparatus, briefly, 
consists of a 7H wide duraluminum horseshoe frame, which is shaped like a 
traction bow and fits well ove£ the patient’s head. To this frame stain- 
less steel pins with blunt ends are attached after their insertion into 
the cranium 3 cm above and 1 cm posterior to the pinna of the ear. The 
insertion of these pins is done under local anesthetic without incising 
the scalp and there are necessary safeguards and protective plates which 
are used to prevent injury to the cranial content. The pins are inserted 
into the parietal portion of the cranium at right angles. He has used 
this apparatus on 26 patients and has found that it is comfortable; that 
it can withstand greater traction force than previous apparatus of a like 
nature which he has used and that no adjusting is necessary while the ap- 
paratus is kept in situ. He believes that this apparatus fulfills the cri- 
teria sought better than previously used similar tongs. 
Pincock and Pava (Hi) have devised §n appliance for inserting one or 
more Kirchner wires or metallic pins through bone, particularly in the 
treatment of a fractured mandible or other Jaw bones. This device aids 
in applying a wire across the fracture, then allowing the removal of the device. The ends of the Kirchner wire are buried beneath the skin until 
ready for removal. With this device, it is felt that oral hygiene and 
normal mouth functions are more readily maintained than with other appli- 
ances now in use. 
Eggers (l£) has demonstrated that fracture ends of bone fragments 
show variable absorption of the surfaces, both clinically and microscopi- 
cally. Even in the most accurate reduction, the usual commercial plate 
actually results in holding the bone surfaces apart, producing delayed or 
non-union. Therefore he designed the contact splint, which is a slotted 
type of plate held in place by the necessary screws, which are not in- 
serted to a point of tightness to produce binding of the splint to the 
bone. The screws are applied as far from the fracture line as possible. 
The resulting muscle pull produces constant and continuing apposition of 
the fractured surfaces. 
(Ed. note: The advantages and physiological correctness are discussed 
in simple and convincing detail in this article and it is felt that this 
new device is a definite forward step in both the understanding of bone 
healing and strengthening of the armamentarium now in use for the internal 
fixation of fractures. The mechanical forces producing locking at the frac- 
ture site, even though the contact splint is not applied tightly to the cor- 
tex of the bone, are well described in this article.) 
Zuelzer (16) reports on an indirect method of fixation of small frac- 
ture fragments with the help of a hook plate. A single Lane plate can be 
used on such small fracture fragments and fractures such as the medial malle- 
olus, olecranon, tibial plateau, where periosteal suturing or wiring will 
not suffice. Hook-plate fixation can be used away from the joints and in 
cortical bone. Damage to joint is avoided and small fragments are not split 
by screws. Circulation and joint surface is not impaired. This is indirect 
fixation. 
(Ed. note: We have used a similar principle about the malleoli, with 
a small hook-plate prepared from ordinary Lane plate by cutting out the 
end screw holes and find it a very suitable method.) 
Results of recent studies and experiments concerning metals used in 
the internal fixation of fractures are reported by Stuck and Venable (17)• 
No single standardized metal has been decided upon as proper for use in 
internal fixation. Vitallium plates and screws are definitely more inert 
than the various alloys of stainless steels so far studied and used. 
Stainless steel alloy, so-called "18-8 SMO% is the best alloy so far 
obtained and has the advantage of strength and uniformity. However, it 
has not proven as inert as vitallium in vivo. Therefore, the surgeon is 
left with the choice of either 18-8-SMO or vitallium. Neither type of 
metal should be combined in a single operation. 
According to Herschell and Scales (18), plastic splints and appliances 
must have the following desirable properties: durability; ease of manipu- 
lation; cheapness; light weight; radiolucency; transparency; inertness and 
freedom from irritants. All of the usual splints and casts may now be made 
of plastics with little equipment in many cases. Littler and Tobin (19) describe a thumb abduction splint made of an 
arc of brass or steel set in a forearm cuff• This splint allows thumb ab- 
duction with counterpressure on the second metacarpal so that radial devi- 
ation of the hand does not occur. 
Wheat (20) uses an apparatus for maintaining rotation of the lower ex- 
tremity while in traction. The author states that Russell's traction, 
which is commonly used for fractures of the neck or trochanter of the femur, 
has the disadvantage of skin traction and of not holding the limb in proper 
internal rotation until healing occurs. To prevent these difficulties, the 
author has employed this routine: Sodium pentothal anesthesia] Kirschner 
wire through the lower tibia; a well padded plaster boot with .the dorsum of 
the foot and ankle cut out for active motion. Apparatus applied to Kirsch- 
ner wire and traction applied to cast. Apparatus consists of two tubes, 
26" long, held by movable crosspieces at each end to adjust the width. These 
tubes are slotted to allow motion of the upright assembly in a longitudinal 
plane. The uprights are Joined at their bases to a freely movable crosspiece, 
to which is fixed a small foot plate. The uprights are furnished with ad- 
justable fixtures with apertures which loosely hold the Kirschner wire. 
Up-and-down adjustment of the fixtures provides the desired degree of rotation. 
Imrie (21) describes the control of the position of the lower extremity 
by an elastic bandage. When a lower extremity assumes an unnatural position, 
usually external rotation and hip flexion, as in the muscle imbalance seen 
in some poliomyelitis cases, the extremity can be easily returned to a neu- 
tral position by use of an elastic bandage single hip spica placed over 
padding. 
Terhune (22) reports on an apparatus for correction of flexion deform- 
ity of the knee, which he has used successfully on the principle described 
by Horwitz. Turnbuckles are replaced by rubber bands. Most important ad- 
vantage is that the patient can constantly exercise the muscles and the 
knee joint. Pressure ulcers frequently seen in turnbuckle casts are much 
less frequent in rubber band traction. 
Urist, Ries and Quigley (23) describe a plaster traction splint for 
compound comminuted fractures of the tibia and fibula. This was used in 
65 battle-incurred injuries of these bones and 11 other simple and com- 
pound comminuted fractures, A traction splint, made of materials in the 
usual supply, consists of a plaster cylinder padded with felt in the upper 
thigh, popliteal, and malleolar regions, and is applied from the groin to 
the ankle while the knee and hip are flexed at U5°« "U" shaped wire loops 
of #12 iron wire or similar metal rod are incorporated in the cast at mid- 
th igh and malleolar levels, A heavier or two similar wire loops are in- 
corporated at the knee. A Pearson attachment, with a pulley fastened to 
the crossbar, is placed over the leg in sagittal plane and attached to the 
hoop at the knee. The ends of the wire at the malleolar level are wound 
around the Pearson attachment. The anterior portion of the cast is cut out 
from the superior pole of the patella to the ankle. The leg is suspended 
in a Balkan frame. The foot is supported by stockinette or moleskin sling. 
Patient can be placed in a wheelchair with this traction after acute pain- 
ful period is over. 
The results of clinical tests with Aire-Lite, a glass plastic material 
used as a substitute for plaster of paris, is reported by Russell, Bateson 
and Loos (2U). They claim this material has the following advantages: 1. Extremely light, strong and resilient. 2. Unaffected by water or 
usual solutions. 3. Waterproof to scrubbing. Non-irritating to 
skin. 5, Transparent to x-rays, obviating removal of fixation for later 
progress films when not necessary. 6. Non-toxic. ?• Gan be autoclaved. 
8, Easily cut by plaster cutters. 9* One bandage equal to several layers 
of plaster of paris. 10. Readily conforms to all bodily contours. 11. 
Can be applied skintight or over padding. 12. Non-cohesive to other ma- 
terials. 13* Subsequent reinforcements readily fuse to original cast. 
1U. Fluid available for softening cast to remove with scissors, l£. Elas- 
tic when applied. 
Padded versus skin-tight Unna’s boot and similar types of leg bandage 
is discussed by Qrbach (25), who urges all practitioners to adopt his padded 
Unna Paste Boot, which consists of the following layers in this orders 1. 
A layer of zinc paste direct to the skin. 2. A single layer of dry wide- 
mesh 311 gauze bandage. 3* A single layer of sheet wadding. U. A k"wide mesh 
gauze bandage, saturated with zinc-gelatin mixture. This layer must then 
be painted (reinforced with warm liquified zinc-gelatin mixture). From Or- 
bach's experience the Unna Paste Boot, applied directly to the skin, has 
caused phlebitic and necrotic ulcers; therefore he believes his modification 
to be an advantage. 
Boone (26) recommends a rocker type of walker for fractures below the 
knee. His device is made of pine or aluminum, with a rubber sole, attached 
to steel uprights and triangular side pieces. This brings the apex of the 
convexity of the walking surface in the weight-bearing line and allows a 
normal walking motion. 
(Ed. note: We have used a similar type of walker of simple wood con- 
struction and ruboer sole without uprights and are convinced that the pa- 
tients are More comfortable in walking with this than the single U-shaped 
type of caliper in common use.) 
In the quest for an improved walker for casts, Thompson and Plewes 
(2?) have designed a wood-soled boot to be worn on the foot of the cast 
as qne would wear a shoe on an uncovered foot. A sorbo rubber instep 
provides springiness; leather straps provide support and enable the patient 
to remove the boot when sleeping, thus preventing soiling of the linen, and 
the boot itself presents a smart appearance. The boot weighs 1.5 pounds. 
(Ed. note; Although the authors claim normal heel and toe motion is 
possible, it would seem that the wooden sole precludes such.) 
Knudson (28) reviews the progress of Physical Medicine pointing out 
the importance of good braces for the thousands of paraplegics and poten- 
tial users of braces cared for by the Veterans Administration Facility. 
No new brace device or development was mentioned. The importance of the 
brace maker to the patient was stressed, as well as the magnitude of the 
jobbing performed by the Veterans Administration. 
Orthopedic appliances in the rehabilitation of patients with spinal 
cord injuries are discussed by Bickers (29)• (Ed. note; It is believed that all orthopedic surgeons and neuro- 
surgeons engaged in treating paraplegics or patients with spinal cord 
pathology should review this article from the standpoint of fitting braces.) 
Approaching the problem of fitting walking caliper braces to those pa- 
tients needing ischial support, Howard (30) stresses simplicity and deplores 
variation in the caliper ring. He introduces a ring which he has found suit- 
able for all except the very fat types of patients. This ring is ovoid in 
shape with an indentation at the postero-raedial section and a sharp drop 
just posterior to the medial side member. It is essential that the slope 
of the posterior section of the ring terminates midway between the medial 
and lateral side members and from this point to the indented section the 
ring must be perfectly horizontal to prevent the tuber ischii gravitating 
to the perineal section of the ring, which causes an internal rotation of 
the limb in walking. He prefers a wide U” to anterior soft leather 
tray (cuff) to prevent the tuber ischii slipping forward. This cuff should 
be tightly adjustable with straps and buckles. The only other supports then 
become a knee cap and a calf cuff. 
A device in which springs replace the action of paralyzed muscles of 
the arm is described ip detail by Ward, Bohlman and Wood (31). A brachial 
plexus type of palsy, with loss of abduction, external rotation at the 
shoulders, loss of flexion at the elbow and some degree of weakness of 
wrist extension occurred in one of the authors as the result of a spinal 
cord tumor. This prosthesis is described in detail and consists of antag- 
onist springs which were substituted for the affected muscles and which 
were very accurately gauged to produce a floating mechanism of the shoulder, 
elbow and wrist joint functions. The author, a surgeon, was able to return 
to a daily normal routine of gardening, driving his car, and resume his 
active practice of general surgery. 
Bailey (32) discusses a rotatory frame for plaster beds. The frame 
consists of a wooden base with three crossbearers which, instead of sup- 
porting a plaster shell direct, are grooved to take three circular discs. 
Each disc is divided in half and .each half shaped to the respective an- 
terior and posterior shells centrally, leaving the circular periphery to 
rotate on the grooved frame. The author claims the advantage that the 
nurse can rotate the body cast patients 100° very easily. The disadvan- 
tage is that the new discs must be fashioned centrally for each new body 
cast. 
Hipps (33) describes a broad canvas sling, the ends of which are at- 
tached to a rope passing through an overhead pulley. With this aid, a pa- 
tient in a cast may turn himself in bed by pulling the rope on the side to 
which he wishes to turn. 
Allen (3U) describes a wedge pillow made of wood in a triangular 
shape padded on its sloping surfaces. She states that it makes a very 
satisfactory device for maintaining hyperextension of the spine. This 
affords rest from the supine position on the Whitman frame without inter- 
fering with the essential corrective position. Being made of wood, it of- 
fers firm support, more effective than from the use of feather pillows. The 
base of the wedge is 22” long and 30” wide. The height is 8 1/2” and the top padded surface 2k11 long* If additional hyperextension is needed, the 
wedge may be made higher or it may be used as a firm base on which addi- 
tional pillows are placed. The size and height of the wedges used can be 
varied. 
Ferguson (35) describes a raobilizer attachment for the Stryker frame. 
The attachment consists of a child's tricycle wheels and propulsion mech- 
anism, which is used by the patient, developing and keeping his non-paralyzed 
upper extremities in tone. 
Procedures 
Caldwell (36) discusses orthopedic problems and prosthetics. Methods 
in control or elimination of infection of bones and joints; measures to 
insure and hasten bony union by improved appliances and bone grafts; and 
production of more comfortable efficient lives for amputees are reviewed. 
Chronic osteomyelitis, being the result of low-grade mixed infection and 
poor circulation, should be combated and is improved by physical therapy 
and then careful surgery. Bone graft technique studies show that cancel- 
lous bone is better except for weight bearing, where both cortical and can- 
cellous bone should be used. Stimulation of bone healing with acetyl thy- 
roxin and choline have not produced any results. Studies of metallic 
plates and alloys have showed that in vitro resistal KA 2 steel was best, 
with less reaction. The work of the Panel on Amputations of the National 
Research Council was discussed and its recommendations listed for hooks, 
elbow joints, plastic hand gloves, ankle joints, lever joints, plastic 
sockets, etc. 
Lowry (37) analyzes 721 war wounds in 360 consecutive cases incurred 
in world War II and shows not only the important contribution of secondary 
closure of wounds in reparative surgery but significantly proves that the 
optimum time for closure is on the Uth or 5th day after injury and/or ini- 
tial surgery. Delayed closure of wounds should not be forgotten in the 
postwar era, especially for the management o' trauma associated with 
severe contamination, marked destruction of tissue or prolonged lag be- 
tween injury and treatment. 
Clark and 'wolfson (36) report on a series of 130 stellate ganglion 
blocks using local anesthesia. The authors describe a technique of la- 
teral approach that they feel has the advantage of relative safety, since 
no vital structures are traversed, as well as ease in changing the direc- 
tion of the needle, since bony contact is made at a depth of 1 to 3 cm 
rather than the 5 to 7 cm depth common to other methods. The results of 
the blocks were not spectacular. Of 130 blocks, only U gave relief over 
ten days; however, in most other cases, the need for narcotics and seda- 
tives was considerably diminished. The types of cases which were so 
treated included practically all types of painful stumps and upper extremi- 
ties, for which this type of therapy has been tried. 
Breck, Basom and Sims (39) report their method of holding corrective 
osteotomies of long bones in their proper positions by the use of oroperly 
bent 6-hole vitallium plates. They feel that the use of internal fixation in this manner, in addition to plaster, assures more successful and desirable 
results and that this method offers a definite advantage over other methods 
for older children, adolescents and adults. The method is presented to call 
attention to this valuable adjunct in crippled childrens surgery. Three 
cases are presented, illustrating three different types of osteotomy in 
which this method was used, A severe genu valgum following knee fusion for 
tuberculosis, an adduction contracture of the hip following fusion for tu- 
berculosis, and a deformity of the femur following poliomyelitis were 
treated by osteotomy held by bent plates. The authors do not claim that 
this is an original or new method but are simply calling attention to this 
aid. 
Scuderi (UO) describes a technique for performing the Lorenz* osteo- 
tomy in cases of ununited fractures of the neck of the femur. In this 
self-centering Lorenz osteotomy of the neck of the femur, a wVfl cutting of 
the femur is performed just above the superior border of the lesser tro- 
chanter. The advantage of this is that the shaft does not then tend to 
displace anteriorly or posteriorly beneath the stump of the neck, which is 
the usual cause of failure in using the straight osteotomy. 
Hoyt and Baker (hi) present £6 cases in which they used interfacet vi- 
tallium screws in a Hibbs type of spinal fusion. In these 52 cases, which 
were followed for one year or more, results were excellent in 225 good in 
22; fair in 6 and poor in 2. Their technique consists in using 5/8" to 
3/U” screws, which are inserted at 20 to 25° inferiorly and 10 to 15° la- 
terally across the facets. No tibial grafts are used. Additional bone is 
obtained from the sacrum or ilium when needed. 
The so-called MH,t type of graft for lumbosacral fusion is reported by 
Altenberg (U2). The technique for the double notch graft is described in 
detail. The author uses both iliac and tibial bone. The graft is applied 
while patient is flexed and upon extension of the spine is locked into 
place. Tibial bone is used for H-graft; iliac bone for the surrounding 
area. Early ambulation follows and the patient is fitted with a brace 
two weeks postoperatively and followed for six months. 3h cases were re- 
ported with failure of fusion of two cases and functional failure in one, 
giving a total of 12,5$ poor results. 
/ (Ed, note: This type of H-graft has been used from the ilium alone 
by the reviewer and considered quite satisfactory without the addition of 
the tibia.) 
Gibson and Loadman (1*3) conclude that the cortical onlay graft fixed 
with vitallium or stainless steel screws is the most efficient treatment 
for ununited fractures, or for bridging short defects in the radius, ulna, 
humerus or femur. This conclusion was reached by analyzing a series of 
105 cases in which bone grafting was performed for non-union or bone de- 
fects, 93 cases were successful. Cortical onlay grafts gave 79$ union; 
cortical inlay grafts gave 81$ union; cancellous bone alone gave 87$ union 
but when combined with a metal plate 69$ union occurred. 
Henry (Ii-U) discusses homografts in orthopedic surgery. He feels that 
they have a definite place in treatment when a sufficient quantity or 
quality of bone cannot be obtained from the patient with ease or safety. During the past years in which homografting has been more or less used, 
there has been no factual evidence that this is an unsound surgical pro- 
cedure. 
Brown and DeMere (U!>) discuss the use of homogenous cartilage graft 
bank. The authors describe the technique for obtaining material at autopsy 
from the costal cartilage. Preservation is accomplished in merthiolate 
solution, changed bi-weekly. Sterility is safeguarded by repeated cul- 
tures. Cartilage may be preserved for use up to two years. It may be 
noted that successful preservation and use depends on careful cleaning of 
the material. 
Soderberg (1*6) stresses the use of open flap skin grafting and of the 
tube pedicle graft, giving the advantages and limitations of each. He then 
reports, with illustrations, the use of a combined tube and flap for cover- 
ing very large defects. This method allows the construction of a flap 
which will exactly cover the defect and has the advantage of being suitable 
for intermediate transfer by means of the tube. For example, the wrist may 
be used as an intermediate carrier in a graft from the abdomen to the lower 
extremity. Above all, the author stresses the fact that in any of these 
procedures no attempt at haste should be made. Blood supply is all-important. 
Pratt (I4.7) recommends tendon repair with steel wires. He uses very 
fine steel wire in such cases, following his own experience and observa- 
tion that silk sutures in the ends of severed tendons which were used as 
guides for delayed repair frequently caused sinus formation. The use of 
wire sutures for such guides was followed by its use in both initial and 
delayed repair. or #36 wire threaded on minute needles are used and 
the advantage is claimed that there is less peritendinous reaction with 
scarring and adhesion formation. The technique of* use depends greatly on 
avoidance of kinking of the wire. 
Tantalum wire in surgery is presented by Schlaepfer (1*0), The author 
presents a new type of tantalum wire which he has used for the past 7 months. 
The wire, in contrast to the old wire, is braided. It is a superior, non- 
absorbable, non-scarring, non-reacting suture. He used this in all fields 
of general surgery but his only application to orthopedics was in tendon 
and nerve injury. It is excellent for tendons in that it allows much ear- 
lier motion without reaction than was previously possible with silk and 
cotton sutures. The author advocates the use of short-wave diathermy to 
promote the early healing of wounds. No reactions have occurred when 
short wave diathermy has been used with braided tantalum wire. 
A simplified technique for patellectomy is described by Boyd and Haw- 
kins (1*9). Through an anteromedial parapatellar incision, the quadriceps 
expansion is incised longitudinally in the raidline, prolonging the incision 
into the patellar and quadriceps tendons for 1 cm. The patella is then 
split longitudinally and each half removed by sharp dissection. The ex- 
tensor apparatus is then closed by imbrication. This method eliminates 
the tension encountered in methods requiring transverse closure. 
Beaded wire in treatment of slipped epiphysis of the head of the femur 
is strongly recommended in some cases by Schlesinger and Hansen (£0), It is in patients in whom aporeciable slipping has occurred and the epiphy- 
seal line is still not closed that most of the difference of opinion 
exists as to just what type of treatment, conservative or operative, should 
be performed. These patients are those in whom many bad late results have 
also occurred. Forceful manipulation and open reduction have given a high 
incidence of degenerative arthritis after several years whether or not 
aseptic necrosis had occurred. More recently a period of waiting has been 
advocated either with bed rest in traction or internal fixation, until the 
epiphyseal line is closed and then performing the corrective osteotomy. The 
results in these patients appear to have shown a distinct improvement. 
Another treatment which is recommended by the authors in this particular 
group of slipped capital epiphyses would seem to offer a method of reduc- 
tion with less risk. They recommend skeletal traction by means of a beaded 
wire through the lower femur, allowing for a strong continuous pull in the 
long axis of the femur, with an additional pull in the direction of in- 
ternal rotation. The beaded wire is applied with local anesthesia 3/h" 
above the medial condyle of the femur. The approach is from the medial 
side. A small skin incision is made and the wire inserted until the bead 
is felt to rest against the femur. The bow is then applied and the traction 
cord attached. A second cord is then attached to the lateral portion of the 
bow where it grips the wire, pull being made perpendicular to the femur 
in an upward direction. This supplies force in internal rotation and the 
bead prevents slipping of the wire. The authors present their experiences 
in four cases in which this technique was used. Excellent reduction and 
function was obtained in 3 cases. In the case where failure of this method 
occurred, open operation had to be resorted to. 
For the tuberculous patient with advanced cavitation who has undergone 
posterior thoracoplasty and in turn later developed pain in the scapular 
area with a fixed scapula, Weisel and Cassel (£L; describe a partial sca- 
pulectomy through an anterior approach, they have successfully employed 
a second-stage anterior thoracoplasty, together with partial scapulectomy 
and demonstrate that this is an excellent operation to further obtain col- 
lapse and to eliminate scapular complications, especially because the ap- 
proach to, and the completion of the operation is simple and quick, which 
are factors of paramount importance in this type of patient. 
A simple method of measuring and recording movements in Joints is pre- 
sented by Wright and Hilnes (£2), 
(Ed. note: No new methods but a combination of previous systems is 
used to make their system a very complete and thorough one. The equipment 
needed is readily available and for the details the reader is referred to 
their article.) 
Joint measurement is described in detail by Occupational Therapist 
Hurt (53). The methods of measuring range of motion in various joints and 
precautions, with both 360 and 180° systems, are shown as to the expected 
normal range in degrees. 
Dorinson and Wagner (£{*) present an exact technique for clinically 
measuring and recording joint motion. They have endeavored to present a 
standardized system of nomenclature after reviewing the literature. Mea- 
surements are made with the protractor goniometer, using skin-pencil aarks in the axis to be measured. The proposal is made that a joint measurement 
record should show full range; for example, in the normal knee "Extension 
flexion 180° - UO0". 
Hellebrandt and Skowlund and Kelso (55) present new devices for dis- 
ability evaluation. The authors discuss the use of ergograms in evaluating 
disability of the upper extremity. The ergograms give visual evidence on 
a kymographic drum of range of motion and number of repetitions performed 
against test resistances of any motions being studied. It allows objective 
evaluation of initial incapacity, response to treatment and residual limi- 
tation. It may be of value ultimately in determining disability in cases 
in which compensation is a factor. 
Better radiographs are discussed by Johnson (56), pointing out the 
basic factors involved in ootaining good diagnostic films. Four qualities 
essential to good films are; 1. Density. 2. Contrast. 3. Detail. 
1*. Minimal distortion. 
Bone marrow biopsy is obtained by Loge (57) with the aid of a Klima- 
Schlicher sternal puncture needle. The marrow obtained is comparable in 
cellularity with that from the sternum. The method has the advantage of 
using a fixed bone and of being out of the range of vision of an apprehen- 
sive patient. 
In an editorial, Dr.William Dameshek of Boston (58) in discussing 
bone marrow biopsy techniques feels that this diagnostic procedure is a 
necessary one, to be used frequently. In his clinic, preliminary obser- 
vations of 30 comparative sternal, vertebral and iliac crest punctures 
indicate that the results are very similar and he feels that vertebral 
bone marrow puncture biopsy, as described by Loge, has a number of ad- 
vantages • 
Movable Horseshoe for Skeletal Traction 
Dittrich (59) describes the use of the original Kirschner horseshoe 
to obtain tension on the wire, but traction is applied by means of sep- 
arate hooks attached to the wire. This is designed to prevent rotation 
of the wire in the bone and safeguard against infection due to mechanical 
irritation. BIBLIOGRAPHY 
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fice #21*31*1*31, Jan. 13, 191*8 
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32. Bailey, E. T. s Rotatory frame for plaster beds, Proc., Roy. Soc. 
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rotation pedicle transplant for repairs of certain deep surface de- 
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July 191*8 
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Surg., Gynec. and Obst., 86: 357, Mar, 191*8 
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recording movements in joints. Treat. Serv. Bull., 2: 33-1*0, Oct. 
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Aug. 191*8 
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Dec. 19U7 
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obtaining bone marrow. Blood, 3: 198-201*, Feb. 191*8 
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zinische Technik, 1: 11*1-11*2, Nov-Dec. 191*7 SECTION 20 
RESEARCH 
Prepared by Milton S. Thompson, Colonel, M. C., U. S. A. 
and Resident Staff 
1. Metals and Plastics - Rubin, Robertson and Shapiro (1) note that 
pure polythene requires no plasticizers, is chemically inert, does not ad- 
versely affect body tissues, and is unaffected by temperature ranges of 
the human body. The material may be sawed, shaped and sanded, or melted 
and cast. It is sterilized by soaking in ethyl alcohol. The present re- 
port lists its use in nasal, chin, and forehead insertions (13 cases), and 
in one case of ear reconstruction. Illustrations show the excellent re- 
sults obtained. 
Bates and Reiners (2) plead for a trial of zirconium for use in sur- 
gery. They find it is extremely inert chemically and abundant in nature. 
Its electrolytic activity is about the same as tantalum and 18-8 SMO stain- 
less steel. It can be drawn into rods and wire, rolled into plates, and 
machined into screws. Zirconium and tantalum have about the same physical 
properties. However, neither has the strength, ductility, nor elasticity 
of 18-8 SMO. Experimentally in dogs zirconium was tolerated well in bone 
and caused a minimal reaction. It is comparable to tantalum and stainless 
steel when used as a suture material. 
Ingraham, Matson and Alexander (3) in an attempt to solve the problem 
of maintaining artificial sutures made in calvaria of sufferers from cranio- 
synostosis, interposed five substances between artificial sutures in cal- 
varia of monkeys and dogs to try to prevent reformation of synostosis. They 
used fibrin film, oxycel gauze, tantalum, lucite, and polythene. The latter 
three were all satisfactory from theoretical grounds but all offered practi- 
cal difficulties except polythene. Reaction to it amounted to formation of 
a thin fibrous envelope and union of bone was prevented in all cases. 
2, Bone Growth and Development - Anderson and Qreen (U) studied the 
normal growth of the femur and tibia in 2$$ children over a six year period. 
Several tables and curves are given showing normals and comparisons between 
boys and girls. Their roentgenologic technique is described. 
Beal ($) studied the growth records of 201 diabetic children from 
1920 to 1937 and compares them with normal growth records. Numerous growth 
charts and tables are presented. At 1? diabetic boys are 1,9 inches shorter 
than normal, girls 0,6 inches shorter. 
Kaplan (6) measured the thickness of the laminae on 190 vertebral col- 
umns and found an average of $.6 mm in the cervical spine and an average of 
5>,9 mm in the thoracic spine, the right being slightly thicker than the 
left in both regions. He found an average thickness of 6.$ mm in the lum- 
bar spine, but here the loft was slightly thicker than the right. Washburn (7) measured the length of the pubis and ischium on 300 hu- 
man skeletons of known race and sex* The pubis is shorter in negroes than 
in whites• The ischium-pubis index was calculated and averages higher 
in females. He states that in over 90% of skeletons the identity can be 
determined by this index alone, provided major racial groups are treated 
separately. 
Leggett (8) states that age determined by epiphyseal shadows is dif- 
ficult and that few radiologists would care to be exact, even within a 
year* 
Raven (9) in a discussion of the physiology of growth writes that 
intrinsic and extrinsic factors coordinate growth in vivo. The intrinsic 
factors determine the specific growth rate. This basic growth is modified 
by functional, mechanical, nutritive, nervous, and hormonal factors. A 
further factor exists in the difference in growth rates in an organ at 
different times. This has been termed Mgrowth Gradient" which concept the 
author states is inaccurate, "as the growth of each point is characterized 
by at least three values indicating the growth in three perpendicular dir- 
ections." 
Chapchal and Zeldenrust (10) experimentally stimulated bone growth 
by introducing metal and ivory pins into the metaphyses of growing rabbits. 
The authors conclude that the method is not suitable for human practice 
because of its uncertainty, and its production of deformities. 
Vastine, Vastine, and Arango (11) hypothesize that the size, shape, 
and contour of the skeletal system is predetermined by the genes since 
they find that in comparison of roentgenograms of respective bones of iden- 
tical twins there is exact similarity in the detailed ossification of the 
costal cartilages, as well as in the fine bone details. 
Sensenig (12) states that a study of human embryos from the Carnegie 
Collection shows the parts of the vertebrae are formed like cartilage else- 
where by a very dense aggregation of mesenchymal cells which have become 
enlarged and have indistinct boundaries. This is in sharp contrast to the 
development of the centrum of the vertebra which forms from a very loose 
aggregate of sclerotoraic cells which form no compact precartilage mass. 
Towns ley (13) attempts to show that Wolff's law determines arrange- 
ments of bone substance at each stage in the evolving structure of the 
femur throughout the vertebrate kingdom and in the growing human femur. 
Davis (1U) presents a critique on methods of handling growth curves. 
He points out methods of selection of biological material and suggests 
means of portraying resultant data in a meaningful manner. 
Dallenmagne (lf>) reviews the biochemistry of primary bone calcifica- 
tion and points out discrepancies in the original theory. He shows there 
are insufficient cations in the bone to combine with and that the ac- 
tive cation is probably organic in nature. Ca/P ratio rises continually 
as microcrystals of tricalcium phosphate are progressively deposited in 
tissue rich in ions. The C&/P ratio of 1;29 cited by other authors is 
merely a stage along the time curve of ossification. Faff (16) studied the femurs of 7 day chick embryos for two weeks at 
two different pH levels (i.e., pH 7.0-7.3 and pH 7,8-6.0) and found that 
more bone was formed at the lower pH# He claims his findings as strong 
evidence against the widespread belief that the local factor in bone growth 
is an alkaline pH. 
3, Bone and Cartilage Grafts and Bone Healing - McKelvie and Mann 
(17) studied the tibias of rabbits microscopically, one to 120 days after 
transplantation of chipped cancellous bone from their own iliac crests. 
Alkaline phosphatase staining was employed and showed this enzyme absent 
for 10 days, then considerable activity ensued and abundant alkaline phos- 
phatase was seen at the graft edges, with osteoblasts. This activity en- 
gulfs the dead chips and the osteoblasts effect their removal. It is 
pointed out that no alkaline phosphatase occurs in adult bone and that 
the osteoblasts become mainly the bone matrix, - "the fibrous-like non- 
calcifiable structure of adult bone". This enzyme is seen in relation 
to fibroblasts where no bone is being formed. They conclude that alka- 
line phosphatase aids in the formation of bone matrix, rather than in the 
deposition of calcified salts. 
Steinman (18) studied embryonic bone transplants in rabbits attempting 
to eliminate external dynamic forces of Wolff* s law by longitudinal drill 
holes. Drill hole defects were normally repaired without cartilage forma- 
tion by intramembranous replacement. Whan the holes were grafted with 
living embryonic bone the defect was repaired in whole or in part by en- 
dochondral activity, frequently forming a large callus. Adult living and 
boiled bone show no cartilage formation. Whether the embryonic bone directly 
proliferates as chondrocytes or merely has a chemically osteogenic effect is 
not determined. 
Bush and Garber (19) experimented with homogenous bona bank on chin- 
chilla rabbits and learned that bone could be stored at 2U°C for up to 8I4. 
days and still heal when grafted. They report a series of cases in which 
homogenous bone was used in 126 operations on 10U patients. Only 1* com- 
plications occurred; 2 infections, 1 fracture of an onlay graft, and 1 
failure of soft tissue coverage'. It appears that low temperature storage 
is a safe method of preserving bone for a long period. 
Schram and Fosdick (20) report that they were able to stimulate heal- 
ing in long bones by use of artificial material. Working with dogs, both 
ends of the radius were fused to the ulna; then 1 or 2 cm of the radius 
were removed and a tube composed of 95% tricalcium phosphate, 3% calcium 
carbonate and other mineral salts was used to fill the defect. This served 
to protect the initial blood clot, according to the authors, from invasion 
by surrounding differentiated tissue until calcification could take place. 
Bony union occurred in all cases. The experiment, they believe, demon- 
strates that the healing of bone originates in the primitive connective 
tissue of the initial clot. 
Gordon and Warren (21) of Toronto carried out a study to ascertain the 
histologic reactions incurred when healthy young fetal actively growing 
cartilage is transplanted into adult long bone. The material consisted 
of cartilaginous epiphyseal ends of long bone of rabbit feti, diced in 
0.5 mm cubes, and placed in defects of long bones of adult animals. Results were studied by serial histologic sections taken at U-day, 1-week, 
2, 3, 6 and 12-week intervals. Examination of a U-day posttransplant 
showed an absence of necrosis and actively growing cartilage cells. At 
one week the cartilage cells still filled the lacunae but the process of 
ossification continued. At 2 weeks cancellous bone surrounds the carti- 
lage discs. At 3 weeks ossification continues. At 6 weeks continuity of 
bone and cartilage discs was seen. At 7 weeks the remains of the carti- 
lage discs appear as islands of cartilage, walled off by cancellous bone 
with round cells in meshwork and walls of lacunae. At 10-12 weeks, is- 
lands of cartilage remain; cancellous bone was thickened and the mitosis 
of cartilage cells had disappeared. It is not the expected result of 
transplanted epiphyseal cartilage since bizarre exostosis did not result, 
but, even though these young cells of cartilage survive, propensity for 
growth is lost. Replacement of bone follows the already established 
scheme for autogenous cartilage grafts to bone. Erosion in areas between 
cartilage and bone, and round cell infiltration indicate some reaction to 
homogenous material. The reaction peak was days after transplant. 
The authors reached the following conclusions; 1. Fetal rabbit cartilage 
when diced and grafted into long bones of adult animals will survive up to 
3 months. 2. Slow replacement by cancellous bone occurs similar to auto- 
genous grafts of cartilage. 3* No evidence, gross or microscopic, is 
found that fetal tissue after homografting retains any great propensity 
for growth or differentiation. k» Mild local round cell reaction occurs, 
reaching its peak about 6 weeks after transplantation. 
De Bruyn (22) made comparison between transplants of autoplastic 
and homoplastic bone in the thigh muscle of rabbits. No homoplastic trans- 
plants formed bone. Of fresh auto-plastic bone transplants, 11 of 23 
formed bone; of bone marrow, 9 of 12 formed bone; of periosteum, 3 of 12 
formed bone. Of the frozen autoplastic bone transplants, U of 23 formed 
bone and none of 12 frozen periosteum transplants formed bone. This evi- 
dence is somewhat contrary to already existing evidence that transplant 
osteocytes do not participate in the bone formation but that osteogenic 
substances diffuse from the transplant. 
Enneking (23) compared simple, complete fractures in rat tibias with 
partial "saw-cut" fractures in rabbit tibias. The complete fracture 
showed more hemorrhage and inflammation with the complete retardation of 
the endosteal response and partial suppression of the periosteal activity. 
No bone dissolution was noted. Repair was by a heavy external callus with 
chondrocytes arising from the periosteal fibroblasts. (Ed. note: An ex- 
cellent description of bone reconstruction.) 
Baker (2i*) presents a demonstration by photomicrographs of callus 
formation. In the healing of fractures the first sign of bone appeared 
within a week of injury. This bone is of a type called woven bone, which 
is laid down in an irregular interwoven pattern about the blood vessels 
of the granulation tissue instead of the lamellar arrangement of adult 
bone. The rapidly formed woven bone is replaced subsequently by adult 
bone. The formation of cartilage in the early stage depends largely on 
mobility of the fragments. Greater movement causes excessive cartilage 
formation with pseudoarthrosis. The trabeculae of ’’woven bone” in primary 
callus follows the haphazard plan of vascular distribution and the lamellar 
arrangement of adult bone is in accordance with the lines of stress. 
390 Thompson, Ilfeld and others (25) report a clinical evaluation of the 
effect of ACS (aniireticular cytotoxic serum) on the rate of healing of 
fractures in human subjects. Statistically significant x-ray improvement 
was observed but clinical observations were not sufficient to treat statis- 
tically. 
Bacslch and Wyburn (26) found in the literature that muco-protein in- 
hibits local leucocytic response of the host to bacterial invasion and con- 
ducted experiments to determine its role in survival of homografts of the 
cartilage and cornea implanted subcutaneously in guinea pigs, Muco-protein 
is present in large amounts in the interstitial substance of cartilage (chon- 
droitin sulphuric acid). They assume that muco-protein plays an active 
role in maintaining homografts of cartilage intact in the host and suggest 
that homografts of other tissues would be more successful if it were pos- 
sible to endow these tissues with some property of the muco-proteins. 
Day (2?) believes that alveolar bone is the most plastic of all bones, 
since the teeth are continually moving in the alveolar sockets, as a re- 
sult of the various forces which act on them, and that it is constantly 
adapting itself to the changing requirements of the teeth. 
1;. Bone Formation and Destruction - Freedman and Forster (28) dis- 
cuss bone formation and destruction in hyperostoses of bones of the skull 
with meningiomas. In general the literature reveals explanations based on 
trauma, vascular disturbances, or reactions of the bone to infiltrating 
tumor. Histologic studies are presented of seven cases which seem to in- 
dicate that bone growth and destruction is the function of the tumor cells 
which can produce fibroblasts, osteoblasts, and osteoclasts, or act as the 
latter two without apparent morphological alteration. 
Amprino (29) describes the structural re-arrangement which takes 
place with age in ossified tendons of birds. From this he deduces that 
the structural re-arrangement of bone matrix depends largely on the con- 
tinued deposition and resorption of mineral salts. 
Evans, Lissner, and Pedersen (30) studied the patterns of stress 
when femora, coated with lacquer, were subjected to static or dynamically 
applied loads. The superior aspect of the neck and the anterolateral (con- 
vex) aspect of the shaft are under tension stress, while the opposite 
aspects are under compression stress. They suggest that this offers an 
explanation for fractures due to sudden violent muscle exertion. 
Sherman (31) reports a case of a woman of 58 in whom many bones had 
almost disappeared as a result of Paget's disease and osteoporosis. Mas- 
sive estrogen therapy was followed almost at once by a remission of clini- 
cal symptoms and by actual reconstitution of bone. Withdrawal of estrogen 
produced an exacerbation. Improvement again followed re-administration, 
A daily maintenance doee of from 2,000 to 10,000 rat units (0.33 to 1,66 mg) 
of estradiol benzoate was given with continued improvement and without uu- 
toward symptoms. Photomicrographs of sections taken from the bone before 
and after instituting estrogen therapy showed definite increase in the bone 
following treatment. Colonna and Jones (32) produced caisson disease in rabbits and studied 
the bone to investigate pathogenesis of aseptic necrosis* The nitrogen 
bubbles in the marrow caused permanent cavities and are believed to be fore- 
runners of aseptic necrosis of bone. 
Rosin and Rachmilewitz (33) exposed bone marrow from rabbit tibias to 
mixtures of atmosphere containing from one to fifty percent oxygen. Micro- 
scopically, various degrees of degeneration and lessened mitotic activity 
were seen in concentrations of oxygen from one to twelve percent* Those 
in fifteen percent were similar to controls, whereas, those in fifty per- 
cent oxygen showed a marked increase in number of mature cells and degree 
of maturation* 
Bywaters (3h) describes a method of measuring bone opacity* It in- 
volves the simultaneous exposure of a graded series of radio-opaque cylinders. 
It is useful method of measuring bone rarefaction* 
Campbell (3!>) studied electrolytic decalcification and observes that 
neither agitation nor placing the bone specimen at the positive electrode 
hastened decalcification. He feels that the electrolytic method is one of 
the best for preserving histologic detail* 
f>. Tissue Healing Studies - Lounsbury (36) conducted experiments to 
determine the tensile strength of tendon repair* The control dogs were 
placed in casts* One group broke out of their casts and showed 71 percent 
greater tensile strength at the end of six weeks than the controls. The 
groups in which muscle tonus was eliminated by denervation had thirty-seven 
percent less tensile strength than the controls. 
Paul, Paul, et al (37) measured the water and protein content of the 
skin of rats during the repair of skin wounds* They found that the water 
content was higher during early stages of healing, approaching normal at 
about the 18th day, at which time wounds appeared healed. The protein con- 
tent of scar was lower than normal in the early stages of healing and rose 
to normal at approximately the 18th day* 
6. Vascular Studies - Kaplan (38) writes of the variations of the 
subclavian vessels• Normally the artery is behind and the vein in front 
of the scalenus anterior muscle. The muscle may be absent and the vessels 
in contact. Either the vein or the artery may be doubled or may form a 
ring with one branch or limb passing in front and the other behind the muscle. 
In rare instances there may be a reversal of the normal positions. (Ed. note: 
No percentages are given for the anomalies, but the author has found that 
the double artery or vein is the most frequent departure from the normal 
arrangement.) 
Halperin and Co-workers (39) studied the effects of pneumatic cuff 
compression upon the blood now in man. They used thermometric, blood 
gasometrie, and plethysmographic methods for estimating blood flow in the 
extremities and found pressure as small as 10mm of mercury sufficient to 
reduce circulation in normal limbs. "Thus, pressure on the extremities, 
such as those ordinarily produced by snug clothing, gloves, shoes, bandages or splints, or by the weight of the limbs themselves, or even the bed clothes 
upon the bony prominences, may be sufficient to cause significant reduction 
in the circulation of normal limbs•" 
Marple (1*0) summarizes the results of Barcroft and Edhoim (Lancet, 2: 
513, 191*6) on their plethysmographic studies of vessels supplying forearm 
muscles. Their findings show that (a) relief of sympathetic vasoconstrictor 
tone in vessels and skeletal muscles doubles the blood flow; (b) heating the 
body relaxes the vasoconstrictor tone; (c) vasoconstrictor tone gradually 
returned to vessels in sympathectomized subjects; (d) vasodilation in the 
forearm muscles under such conditions as fainting and probably not exercise 
ii'function of vasodilator nerves in sympathectomized subjects. Muscle 
contraction can bring about vasodilation. 
Hollis, et al (1*1) made a comparison of three cases of peripheral vas- 
cular disease with respect to the blood flow in the lower extremities. They 
obtained greater increase of blood flow by sympathetic block of paraverte- 
bral ganglion than they did by intravenous injection of tetraethyl ammonium 
chloride in recommended dosages. 
Harman (1*2) shows by means of experiments with rabbits that ischemic 
necrosis of skeletal muscle is not a major function of arterial spasm or 
venous obstruction, but of the persistence of initial ischemic damage to 
the capillary bed in the musculature involved. Angiographic and histologi- 
cal studies are presented. 
Keplan and Joseph (1*3) determined the circulation rate in articular 
structures by increasing the temperature within the knee joints of dogs 
and observing the subsequent rate of cooling. They state that the normal 
circulation rate in articular structures is 0,75 cc per minute per cc of 
static fluid. 
Wise (1*1*) by plethysmograph readings shows that diathermy causes an 
increase in arterial blood flow to the segment of the body exposed to it. 
Kemp, et al (1*5) found that diathermy applied to the hind limbs of 
dogs sufficient to elevate temperature, caused decrease of blood flow. 
When microwave energy was applied in the same way the blood flow was in- 
creased. 
Kleinsasser (1*6) analyzes his observations of 502 cases of intravenous 
clotting seen in three large Army Vascular Centers, 12$ of the cases pre- 
sented no sequelae, 37*8$ were partially disabled, and the greatest offender 
was persistent swelling. He is convinced that vasodilatation is necessary 
in treatment of thrombophlebitis; that propagation of thrombus and embolism 
must be prevented in phlebothrombosis, To avoid lymphedema as many colla- 
terals as possible must be saved and early treatment is essential. Anti- 
coagulants should be started as soon as diagnosis of intravenous clotting 
is made, regardless of other modes of treatment chosen. 
7. Muscle Histologic Studies - Hanisch (1*7) presents a general re- 
view of the anatomy, histology, and physiology of muscle in which a com- 
prehensive, but rather elementary, compilation of the known facts about normal muscle have been assembled in one article. Practically every a; 
pect of the subject is covered except the gross anatomy of individual 
muscles and the sections on muscle action and muscle mechanics are es- 
pecially valuable for the completeness and clarity. 
Herman and Gwinn (U8) studied histologically and chemically the ne- 
crosis of muscle in acute ischemia. It is noted that ischemia produces 
necrosis which reaches a maximum three hours after the tourniquet is re- 
moved and is proportional to the duration of the ischemia. Even when 
muscles are ischemic four hours, 8(# regain ability to contract upon fa- 
radic stimulation after 2k hours. By chemical studies it was proven that 
glycogen, adenylpyophosphate, and phosphocreatin, are completely hydrolyzed, 
and then are resynthesized in these muscles to some extent after 2k hours. 
They suggest that depletion of these compounds starts destruction of cells* 
Johnson (U9) studied the histogenesis of myositis ossificans in 70 
cases. The early cases showed distinct layers, the center consisting of 
hemorrhage and debris, the first layer being the gelatinous myxomatous 
tissue, and the other layer being damaged muscle* The first layer rapidly 
forms two more layers, the outer one of which produces bone matrix and 
cellular activity resembling bone sarcoma until it ends as a shell of 
hard bone. The inner develops giant cells and resembles a giant cell 
tumor until it quiets down and ends as connective tissue. After the third 
month the histological appearance is definitely benign and many cases end 
with a hollow shell of bone. 
8. Muscle Chemical Studies - Nicholas and Herrmann (50) in an arti- 
cle entitled "Chemical studies on developing muscle” studied the relative 
appearance of muscle protein in the rat from 12 days development to adult- 
hood. Fractions were determined by extraction. Residue is 3*5$ in the 12 
day embryo, 5*5$ at birth, 7% at 15 days, 6% at 27 days* 
Steinbach (51) examined the role of the ions in muscles and their 
influence on muscle structure, fatigue, and the enzymatic systems. The 
author believes that intracellular cations are not evenly distributed 
within the cell1s structure and that they show decided influence on the 
muscular enzymatic systems. Potassium and sodium were investigated care- 
fully and very large changes in concentration will not impair the muscle’s 
ability to perform work. He feels that these ions form a labile equili- 
brum with similar ions outside the cells. Structural adjustment of ions 
is made when this equilibrum is upset. 
Acheson (52) in a discussion of the physiology of neuromuscular junc- 
tions from the chemical point of view, states that the most significant 
advances in neuromuscular soadies has been in the electrical realm. A 
very detailed account of these developments is presented. 
Acheson, et al (53) in an attempt to evaluate the sensitivity of my- 
asthenia gravis patients to acetyl choline, administered it intra-arterially 
to five normal and five myasthenic subjects, and measured muscular contrac- 
tions, It was concluded from the small series that there was no signifi- 
cant difference between the two groups. In fact, considerable variation 
occurred when the same dose was injected repeatedly in the same subjects. Harvey (5U) discusses the use of tetra-ethyl-pyrophosphate in the 
treatment of myasthenia gravis. It appealed to be just as effective as 
neostigmine. The effect of the potassium level as regards neuromuscular 
function is also discussed. He reports cases of both low and high serum 
potassium levels who developed an ascending type of muscular paralysis. 
This action, he feels, may be due to a primary defect in the muscles 
themselves• 
9. Muscle Physical Studies - Sheman (55) reports his investigations 
with the development and treatment of contractures in the muscles of the 
cat*s leg, following experimentally produced lesions of the sciatic nerve. 
The materials, methods, and types of treatment are given and the results 
are shown by several figures and tables. Immobilization of a normal ex- 
tremity did not produce contractures. Following denervation, contractures 
began to develop in 30 to 1*5 days. Contractures occurred in 81*.2$ of the 
cases sifter primary suture and in 100$ after delayed suture. Residual 
contractures were more frequent after delayed than after primary suture. 
Massage and passive motion decreased the frequency and severity of con- 
tractures. The addition of electrotherapy to massage and passive motion 
delays the appearance of contractures for a longer period of time after 
primary suture, and may have some benefit in the early post-operative 
period. Electrotherapy favors the development of contractures in the un- 
paralyzed antagonists of paralyzed muscles, and retards the dissolution 
of contractures which occur after delayed suture. Contractures were more 
frequent following section of the sciatic nerve if the extremity was im- 
mobilized than if permitted to be free. Spontaneous movement after re- 
covery of function serves to dissipate a contracture. 
Kinard (56) found that in 33 subjects, who were trained, there was 
no significant degree of correlation between ischemic work ability and 
absolute muscle power. It is concluded that ischemic work ability and 
absolute muscle power are unrelated and probably depend upon different 
processes in muscle. 
Alexander and Co-workers (57) report further experiments in bridging 
nerve gaps in monkeys. TKirty-two mm. gaps in tibial nerves were closed 
by nylon cables and embedded in tubulated blood bridges. Then re-innervated 
muscles regained an average of 85$ of their normal weight. The distal re- 
generated nerve fibers were normal in number but subnormal in size. Func- 
tional recovery was grossly complete. 
Schiller (58) studies bone changes produced by injury to peripheral 
nerves. In cats the sciatic nerve was sectioned below the sciatic notch. 
Bone changes were noted only when ulceration had occurred at heel or knee. 
These consisted of slight atrophy of the tarsal bones. Legs immobilized 
but without ulcers showed no demonstrable bone change. He concludes from 
the experiment that atrophy of bone does not result from denervation of an 
extremity nor from immobilization of a denervated extremity. 
10. Phosphatase Studies - Kirk and Jackson (59) review calcium, phos- 
phorus, and phosphatase metabolism, and the relationship of vitamin D, para- 
thyroid extract and dihydrotachysterol. Phosphorus is decreased in hyper- 
parathyroidism and rickets. It is increased in renal rickets and hypopara- 
thyroidism. The toxic symptoms recognized by Windaus, following the ingestion of 
large amounts of vitamin D are mentioned, and the two functions of vitamin 
D described as increasing calcium absorption and phosphorus excretion. 
The same authors (60) review a series of hospital cases of hyperpara- 
thyroidism and Paget1s disease and describe the symptomatology, physical 
and laboratory findings. 
King and Delory (61) review the literature on phosphatases. Alkaline 
phosphatase in the absence of jaundice is associated with osteoblastic ac- 
tivity. Normal values vary with methods; Bodansky l-U; Jenner and Kay, 
3-8; King and Armstrong, 3-13. An increased level is typically present in 
Paget's disease, osteitis fibrosis cystica, rickets, and osteomalacia. The 
principal source of acid phosphatase is the action of the cells of the pros- 
tatic epithelium. Normal values are; Sullivan, 1-3; Watkinson, 1-5; Her- 
bert, 1-5; Huggins and Hodges, 3*5 to 1.37. It is raised in cancer of the 
prostate while alkaline phosphatase level is normal. 
Flink (62) discusses calcium, phosphorus, and phosphatase as diagnos- 
tic aids.- Calcium varies in adults from 8.5 mg to 10.5 mg per 100 cc and 
in children from 11.5 mg to 13.5 mg. Serum phosphorus ranges from 2.5 to 
U.O mg per 100 cc in adults and from 0.5 to 5*5 mg in children. Osteoblastic 
activity accounts for the elevation of alkaline phosphatase in rickets, os- 
teomalacia, Paget's disease, renal rickets, hyperparathyroidism, neurofibro- 
matosis of bone, osteogenic sarcoma, carcinomatosis with bone metastases, 
Hodgkin's disease and Qoeck's sarcoid. Jaundice, extensive fracture in the 
healing phase, and the last trimester of pregnancy can also cause increase 
in alkaline phosphatase. Low alkaline phosphatase is seen in cretinism 
and scurvy. 
Hinchey (63) discusses the role of calcium in bone disorders. Theories 
of calcium metabolism are divided into four main categories as follows; 
(1) calcium absorption, (2) blood calcium, (3) calcium excretion, (h) cal- 
cium metabolism in bone. Various bone disorders are presented and dis- 
cussed. Senile osteoporosis is thought to be due to a decreased osteogenic 
activity of the osteoblasts without a parallel retardation of decalcifi- 
cation. Osteomalacia is a failure of calcification of osseous matrix due 
to a lack of availability of calcium. Hyperparathyroidism may be an adenoma 
or hyperplasia of the gland. Hyperthyroidism involves the mechanism of low- 
ering the renal threshold for calcium. . Renal rickets causes acidosis and 
mobilization of calcium. Osteitis deformans is a local destructive process 
followed by compensatory new bone formation and exhaustive hyperparathy- 
roidism. (Ed. note; This seems to be an excellent review of present 
thought on calcium metabolism). 
Bourne, G. H. (6U) shows that there is an accumulation of cells strong 
in phosphatase reaction in guinea pig bones within 2k hours after injury 
and that by three days these cells have nearly gone, but osteogenetic and 
endothelial cells are abundant. All cell types are reduced in number by 
four days in animals on a scorbutic diet* 
Greep and co-workers (65) give a detailed description of the materials 
and procedures used in the decalcification of the hard tissues using the 
396: heads and proximal portion of tibias of 28 day old rats. In evaluating the 
phosphatase activity, they determine that alkaline phosphatase could be 
demonstrated after decalcification in solutions of weak acid buffered to 
pH of ii#8 to 5 with the sodium salts of weak acids. Complete removal of 
mineral required 5 days and when the pH was lower than U.?8 the phospha- 
tase was destroyed. 
Fischer and Creep (66) present their work on the activity of purified 
alkaline phosphatase. They find that the activity lost by standing is re- 
stored temporarily by magnesium ions and more permanently by addition of 
amino acids or commercial trypsin, activation by the latter lasting the 
longest time. They state that their observation suggests that phosphatase 
is a metal protein. 
11. Hormones and Enzymes - Vergara (6?) studied five cases of osteo- 
porosis with the following diagnosesj (T) slipped femoral epiphysis, (2) 
Legg-Perthes* disease, (3) developmental malformations, (1*) congenital 
luxation of the hip and (5) Juvenile rheumatoid arthropathy whose blood 
chemistry was normal. He treated them with anterior hypophysis growth 
extracts and later with extracts of the adrenal cortex and describes the 
satisfactory results achieved. 
Collins and Becks (68) removed the hypophysis from one month old rats 
and studied them up to 639 days. Within 6 days chondrogenesis and osteo- 
genesis ceased. Trabeculae are resorbed from the marrow of the diaphysis. 
The epiphyseal cartilage plate is separated by bone from the marrow cavi- 
ties of the epiphysis and diaphysis and persists in this dormant state. 
Becks, Asllng, et al (69) report further studies of the third meta- 
carpal in the hypophysectomized female rat. Pituitary growth hormone 
given to animals whose epiphyseal plates had been dormant for from 285 
to i;53 days was followed by replacement of the "sealing off bone" by 
capillary tufts. Thyroxin replacement caused closure of the epiphyses. 
The results were inconsistent and thyroxin was not essential. 
The same authors (70) administered pituitary growth hormone to normal 
rats and found gains in body weight and length. The third metacarpal 
showed no increase in length. Epiphyseal closure was neither accelerated 
nor prevented. They conclude that the presence of an intact epiphyseal 
plate is thus not a criterion that growth potentiality exists. 
Zarrow (71) studied the agents responsible for relaxation of the 
symphysis pubis and reviews the background regarding the role of relaxin 
and estradiol and progesterone. Using guinea pigs for the experiment he 
concluded that estradiol has a direct effect upon the symphysis and that 
treatment with relaxin injected into the estrogen primed guinea pig has 
a similar reaction. 
Finkler and Cohn (72) report a case of multiple fibrous dysplasia 
of bone with hypogenitalism, treated with testosterone for one year. There 
were multiloculated cystic areas in all extremities, skull, ribs, and ver- 
tebrae. Treatment was continued fbr one year and a total of 2,200 mg of 
397 testosterone given. There was improvement in general vitality of the 
patient and an increase in height and weight. There was also improvement 
in all bone lesions as shown by x-ray examinations and biopsy. 
Kestler (73) reports the results of 3Hi orthopedic cases with muscu- 
lar spasm treated by histamine. It was given chiefly by iontophoresis 
but supplemented in some instances by intravenous drip. They found that 
in functional disturbances the results are excellent and recurrences few. 
In specific entities such as arthritis, the results were temporarily good. 
He concludes that histamine iontophoresis is a harmless procedure and ap- 
pears to eliminate painful muscle spasms. 
12, Vitamin Studies - Mayer and Krehl (7U) report that in their in- 
vestigation of Vitamin A-l deficiency syndrome in rats they observed symp- 
toms of acute scurvy, bleeding of the lachrymal glands, red, swollen 
gums, and early paralysis of forelegs with swelling of joints. The symp- 
toms subsided following massive doses of Vitamin C. 
Silberberg, et al (75) found in growing Vitamin B deficient rats that 
there is retardation and finally cessation of growth of cartilage and bone 
and atrophy of the bone marrow. Skeletal growth is resumed after refeeding 
on stock diet. 
Nelson, Sulon, et al (76) found in riboflavin deficient rats that the 
growth of the tibia was retarded and endochondral ossification impaired. 
Hematopoietic tissue was replaced by fat in all animals after 1kh days. 
Mulligan and Strieker (77) found that metastatic calcification was 
produced in various organs by feeding high doses of Vitamin D and alkaline 
salt. Without alkaline salt less calcification was found. Atrophy of 
testes, prostate, parathyroid, bone marrow, lymphoid, and adipose tissues 
were noted and relation to possible direct and indirect effects of Vitamin 
D was discussed. 
Fourman and Spray (78) discuss a case of osteomalacia secondary to 
steatorrhea. A low fat diet (30 gr. daily) and supplemental calcium and 
Vitamin D gave no improvement. A diet with 70 gr. of fat, gr. cal- 
cium, and 12,000 units Vitamin D by mouth caused retention of 1,9 gr. 
calcium in 16 days, When Vitamin D was given intramuscularly, 6 gr, of 
calcium was retained in the 16 day period. They therefore recommend 
parenteral Vitamin D and a diet as low in fat as is compatible with pala- 
tability. 
13* Other Metabolic Studies - Johnston (79) reports two cases in 
which calcium was used as a therapeutic agent. The first was for tetany 
following thyroidectomy which was controlled with calcium lactate by 
mouth, calcium gluconate by intramuscular injections, and injections of 
parathormone. Calciferol was used later and is less expensive. The sec- 
ond case is one of lead poisoning with acute abdominal symptoms, 15 cc of 
a 20$ solution of calcium gluconate was given intravenously which quickly 
controlled the abdominal pain. The lead was thereby stored in the bone and 
out of circulation for a few weeks and was again mobilized by giving a low 
calcium diet with potassium iodide or ammonium chloride. 
398 Munro and Cummings (80) present an experimental study of nitrogen 
loss in traumatized femora in rats. Five or six days after injury the 
injured limbs were analyzed for nitrogen content. The total excess ni- 
trogen output in the urine far exceeds that given up by the injured tis- 
sues. 
Burnett, Burrows and Commons (81) studied kidney functions in osteo- 
malacia resulting fran renal acidosis - a syndrome called "tubular-insuf- 
ficiency without glomerular insufficiency". The results suggest gener- 
alized renal impairment but greater relative tubular than glomerular dys- 
function. The acidosis is partially explained by the inability of the 
kidneys to res orb all bicarbomte filtered at low plasma levels of this 
anion. 
Hansen, et al (82) observed over a period of four years that young 
dogs maintained on a low fat diet show a lowered resistance to infection 
such as impetigo, pneumonia and purulent otitis. 
Radiation Studies - Brues (83) gives a general discussion of the 
more common effects of theatomic explosion in Hiroshima. Sterility (usu- 
ally temporary), acute radiation sickness, keloid formations, and aplastic 
anemia were cited. Treatment was discussed. 
Rittenberg (8U) summarizes the use of isotopes in biology and medi- 
cine and by specific example indicates the vast new fields of study made 
available through this technique. He clearly describes some of the newest 
detailed information on intercellular synthesis and degradation obtained 
by the use of labelled nitrogen. 
McDonald (85) writes an introduction to the combined report of the 
Biochemical Research Foundation for 19U7 and attempts to correlate what 
little is known concerning the mechanism of the action of-radiation on 
living cells. He points out that the term radiation is applied to the 
varying action of visible light, ultra-violet light, x-rays, gamma- 
rays, neutrons, etc. Experimental work has shown that specific wave lengths 
of ultra-violet are far more lethal than an enormously greater amount of 
energy delivered by x-rays. He considers the cells as a series of colloid 
systems within colloid systems and states that we know little about what 
part of the vital system is affected by neutrons. The "quantum hit", or 
target theory, which has been advanced to explain variations in radiation 
effect, is that energy is absorbed in quanta and that lethal action de- 
pends on a sufficiently large number of quanta absorbed in a particularly 
sensitive spot of the cell. This he believes inadequate to explain vari- 
able cell effects. He concludes that when this mechanism of the action of 
radiation effects in stopping the growth and division of new cells is dis- 
covered, the problem of cancer will be well on its way to solution. 
Doan, Wiseman, et al (86) make a six year clinical evaluation of in- 
temal radiation iherapy with P32 on the first 100 cases. They state that 
the greatest value has been experienced in controlling the blood and clini- 
cal picture in polycythemia vera and in certain of the more chronic leu- 
kemic conditions, especially that group resistant to radiation therapy. 
399 Silberstein (8?) reviews the literature dealing with radium poisoning 
from 1908 to 19hh* Seventeen deaths followed ingestion* Autopsy is de- 
scribed in nine* In all cases there was an advanced regeneration type of 
anemia, acute leucopenia, and degrees of bone destruction* Six deaths are 
ascribed to inhalation of radioactive dust 5 to l£ years after beginning 
of exposure* Dyspnea and pulmonary fibrosis were prominent signs with 
one having bronchial carcinoma* Distribution and deposition of radium is 
similar to that of calcium and lead* 
l£. Motion Studies - Levens, et al (88) report studies made on the 
transverse rotary motion of various segments of the lower extremities with 
synchronized photographic records made in three planes simultaneously with 
3£mm motion picture cameras of 26 normal subjects. Stainless steel pins 
were drilled into the iliac crest, the adductor tubercle of the femur and 
the tibial tubercle. They show that transverse rotation of the pelvis, 
femur and tibia occur in all normal individuals. Inward rotation takes 
place during the phase of minimal weight bearing to full weight bearing; 
and outward rotation during the phase from full weight bearing to minimal 
load. They believe that the discomfort and awkwardness of a leg brace 
with no rotation at the hip, knee and foot may be overcome by the incor- 
poration of a simple mechanism to provide for this transverse rotation in 
amputees• 
Pomeranz (89) studied the movement of the normal cervical spine in 
flexion and extension by x-ray. He shows that in hyperextension the 
spinous processes in the lower cervical area impinge upon each other while 
higher up they do not come in contact and that the apophyseal joints glide 
backwards as do the bodies. In hyperflexion, the spinous processes are 
widely separated, the facets move forward, and there is slight forward 
luxation of the third, fourth and fifth vertebrae in the normal spine. 
16. Diseases and Malignancy - Messer (90) discusses chemotherapy of 
malignancies in a detailed manner. He describes the action of nitrogen 
mustard, urethane, radioactive isotopes, hormone therapy, toxin therapy, 
and other agents, and concludes that surgery remains the only permanent 
cure*' Both radiation and chemical therapy are palliative measures at best 
and there is invariably a recurrence of the abnormal growth. 
Faloon and Gorham (91) review the actions of mustard compounds bio- 
logically and chemically. In 1$ patients with neoplastic disease who 
received 19 courses of treatment since November 191*6, temporary remissions 
were obtained in treating cases of polycythemia vera, lymphosarcoma and 
disease. Uniformly unsuccessful results in treating leukemias 
agree with the reports of other workers. The substance used was methyl- 
bis (beta-chloroethyl) amine. 
Huss, Gilbert and Liebow (92) report a method of obtaining from the 
spinous processes, bone marrow for biopsy which they believe is more con- 
venient and less dangerous than the method of sternal puncture. They state 
that it has additional value for the detection of metastatic tumor cells 
especially of prostatic carcinoma. 
17. Shemotherapy - Altemeier, et al (93) studied chemotherapy in gas 
gangrene using ariificially made wounds In guinea pigs and standardized 
:*K)o innoculations of Cl. Welch!. Streptomycin was found to have no signifi- 
cant value. Penicillin was shown to have a notable beneficial effect 
which was greatly modified by time of treatment and size of dose. Recom- 
mendations are that in suspected cases of gas gangrene, penicillin thera- 
py should be instituted as soon as possible in conjunction with debride- 
ment at a recommended dosage of 1,000,000 units every three hours. 
Klimek and co-workers (9l|) studied the resistance of staphylococcus 
aureus to various antibiotics. They were able to obtain a strain of sta- 
phylococcus aureus that grew in the presence of U mg of penicillin per ml, 
an increase of resistance of 80,000 times that of the parent organism. Re- 
sistance to streptomycin developed more rapidly. Various other substances 
were studied. Subculturing of a resistant strain in penicillin free broth 
reversed the process so that after 63 transfers the strain was again sus- 
ceptible to 0.1 micrograra per ml of penicillin. 
Bellamy and Klimek (95) produced a resistant staphylococcus in which 
5U transfers in the absence of penicillin did not decrease its resistance. 
An extra cellular penicillinase was produced when grown in the presence 
of penicillin. A reversion from gram-negative rods to the original gram- 
positive staphylococcus forms resulted after serial transfers through a 
medium containing glucose, salts, nicotinic acid, thiamine, and yeast ex- 
tract. A minimum of resistance to penicillin was maintained. 
Jones (96) reports his investigations of the use of local injections 
of penicillin into infected Joints. He believes the intra-articular in- 
jection of 100,000 units effectively protects the Joint for i*8 hours, and 
is the only way of insuring proper concentration within the Joint, Fol- 
lowing intramuscular injection of penicillin the concentration in synovial 
fluid is less than in the blood. Parenteral penicillin injection should be 
used only as an aid to local use in Joint infections. 
18, Gas Gangrene - Caloow and Welch (97) subjected two series of dogs 
to devascularization of the hind quarters to study the prevention of gas 
gangrene* In comparison with a controlled group they reduced the incidence 
of secondary gas gangrene from 71$ to 27$ by (a) supportive therapy by in- 
travenous fluid and transfusion during and after operation, (b) the prepa- 
ration of the operative field as though the wounds were contaminated wounds, 
and (c) by improving the operative technique* Interpolated into terms of 
the devitalized limb in the war wounded, the findings seem to indicate that 
the adequacy of the preparation of the contaminated wound, the debridement 
and the operative technique were large factors in reducing gas gangrene in- 
fections without antibiotics. 
19. Miscellaneous - Wilson (98) reports an experimental study of a 
technique of producing artificial bursae. Cellophane layers were used 
between the layers of a previously scarred subdeltoid bursa in 35 rabbits. 
The cellophane was left in the tissues 29 to li*9 days. 23 of these rab- 
bits developed a bursa composed of a normal appearing surface layer, sup- 
ported by loose connective tissue. There was no sign of change in the 
cellophane and no foreign body reaction about it. The remaining 12 cases 
were unsuccessful because of complicating infection, extrusion or encap- 
sulation of the cellophane. Ingelmrk and Blomgren (99) describe in detail a highly complicated 
electrical apparatus which can measure the pressure in different parts of 
a joint under conditions closely resembling the physiological state, A 
pressure sensitive element, consisting essentially of a rubber membrane, 
is placed between the cartilage surfaces. Measurement is by an electrical 
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& Joint Surg., 30B; 106-109, Feb. 191*8 
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53: 75-91*, 191*8 SECTION 21 
MISCELLANEOUS SUBJECTS 
Prepared by Oral B. Bolibaugh, Colonel, M. C., U. S. A. 
and Staff 
Calcinosis, Vitamin D Toxicity, Heterotopic Bone Formation 
The prescribing of massive doses of vitamin D is not without its 
dangers as shown in the case report cited by McLean and Lebo (1), The 
patient is a 5>6 year old white male whose chief complaints were tiredness, 
weight loss, lack of concentration, frequency of urination, insomnia, and 
pain in the neck, shoulders, knees, ankles, and feet* He had been studied 
two years previously at John Hopkins Hospital where the diagnoses were 
mild hypertension, osteoarthritis of the spine, and a chronic prostatitis. 
Upon his return home, his physician prescribed a streptococcus vaccine and 
6 vitamin capsules a day. The total dose was 180,000 international units 
of vitamin A and international units of vitamin D. 
Examination showed his blood pressure to be 190/100. Positive find- 
ings were no limitation of motion of joints or deformity, but motion of 
the trunk caused pain in the thoracic and lumbar regions. There was a 
slight enlargement of the proximal interphalangeal joint of the right in- 
dex finger and slight crepitation in both shoulder and knee joints. There 
was a moderate benign hypertrophy of the prostate. Blood and urine tests 
were essentially negative. X-rays of the cervical, dorsal and lumbar- 
spines showed hypertrophic changes with extensive calcification of the 
spinal ligaments in the latter areas. 
The patient returned home and continued treatment for osteoarthritis 
and hypothyrddism. Fifteen months later, 5 July 191*6, he returned with 
an aggravation of his symptoms plus persistent nausea, weakness, swelling 
of eyelids and ankles, severe backaches and generalized itching. He 
stated that he had taken the above daily amount of vitamins A and D for 
two and a half years. For one month he noticed a lump in his right glu- 
teal region and painful swellings of his left ring finger, thumb and wrist. 
He was admitted to the Union Memorial Hospital for study. He gave a history 
of twenty pounds weight loss and having difficulty in walking. Examination 
showed a pale skin and mucous membranes, a moderate hypertrophy of his 
heart with a grade I systolic apical murmur, peripheral blood vessels were 
sclerosed, the skin was dry and excoriated (from scratching). The left 
hand showed a cystic enlargement of the proximal interphalangeal joint and 
the tip of the ring finger. The wrist was painful to manipulation. There 
was a globular, cystic, protruding mass, orange sized, in right gluteal 
region which interfered with movements of the hip. Urinalysis showed a 
polyuria and a specific gravity which failed to go over 1.010. There 
was albumin and a few casts and white cells present. The Sulkowitch test 
showed 2 plus, and the phenolsulfonphthalein test showed a 6 percent ex- 
cretion in one hour. Blood calcium was 9*01 mg; inorganic phosphorous 
uio: $.2$ mg; alkaline phosphatase 6*8$ Bodansky units; and acid phosphatase 
28.08 and 27.01 Bodansky units. The Hb was 6? percent, and RBC 3,52. 
The heart showed slight enlargement of the left ventricle; the aorta 
showed some calcification. There was a large area of increased density 
posterior to the upper portion of the shaft of the femur and intertro- 
chanteric region on the right side. Streaks of calcification were noted 
in the soft tissue posterior to the ischia. The deep femoral and poster- 
ior tibial arteries were partly calcified. There were "areas of calcium 
density in the soft tissues of the left hand and wrist medial and poster- 
ior to the ulna and anterolateral to the proximal interphalangeal joint 
as well as the extreme tip of the fourth finger.*1 
The gluteal mass increased in size and became more painful, so was 
excised* Multilocular cysts containing a chalky material was found* The 
cyst on the left ring finger was likewise treated, and the same type of 
material was found. The histological examination showed "calcium deposi- 
tion, osteoid formation, and foreign body reaction"* The calcium in the 
cysts and cyst walls was "surrounded by endothelial macrophages, foreign 
body giant cells and swollen fibroblasts”. Throughout the sections there 
were large, polyhedral cells which were probably of osteoblastic nature* 
The diagnosis was multilocular cysts. The postoperative course was un- 
eventful and following the withdrawal of vitamin D, his symptoms dis- 
appeared* 
The symptoms of such a toxic manifestion ares "weakness, excessive 
fatigue, anorexia, weight loss, generalized pmritis, insomnia, and mus- 
cular pains; also clinical signs of renal failure, albuminuria, casts, 
failure of kidney to concentrate a urine with a specific gravity above 
1*012, as well as reduced phenolsulf onpKWein tests* There was poor 
function of the excretion urogram, azotemia, metastatic calcification 
in the soft tissues and the blood vessels, anemia, and prostatitis*" 
The calcium and phosphorus blood levels were normal, but Freeman has 
stated that this may be preceded by an increased urinary calcium excretion. 
McLean and Lebo were unable to explain the high acid phosphatase. They 
recommend that in patients taking vitamin therapy an unexplainable renal 
insufficiency, anemia, or calcific deposits in the blood vessels or soft 
tissues should mean careful studies to rule out severe toxic manifesta* 
tions of vitamin D poisoning. 
The poisoning can produce symptoms and X-ray and laboratory findings 
of hyperparathyroidism, with or without bone changes, calcium deposition, 
and renal damage which may or may not be reversible. Slocumb (2) states 
that the earliest signs of vitamin D toxicity are "polyuria, polydipsia, 
nausea, vomiting, occipital headache, or pruritis", with laboratory find- 
ings of elevated serum calcium and blood urea and increased urinary ex- 
cretions of calcium. Severe vitamin D poisoning produced deposits of cal- 
cium in nodules, tophi, and arteries, osteoporosis with destructive and 
cystic areas in bones, uremia, and anaemia. Dosages of vitamin D as low 
as 50,000 units daily may produce severe toxic reactions. Vfitamin D is 
prescribed for a variety of arthritides such as osteoarthritis and gout 
as well as for rheumatoid arthritis, and toxic manifestations are becom- 
ing more common, with patients even going to surgery for parathyroidectomies. Dr. Philip S. Hench of Rochester, Minn., states that ,fin a case of acute 
recurrent arthritis with nephritis or stones (radiographically non-opaque), 
think of gout, but in a case of chronic arthritis or even of vague "rheu- 
matism" with nephritis or stones (radiographically visible) think of rheu- 
matoid arthritis with pharmaceutic nephritis, chiefly vitamin D intoxica- 
tion, and less commonly "gold nephritis". The poisoning does produce de- 
posits of calcium in the media of the arteries. 
The Pure Food Department cannot stop the sale of vitamin D prepara- 
tions as long as these preparations are sold on prescription, so it is ac- 
tually up to physicians to be aware of the dangers of vitamin D therapy 
and to prescribe it more wisely. 
Edmonds, Coe and Tabrah (3) add a fourth case of mature, well-developed 
bone in skin, subcutaneous tissue, and muscle to three cases as occurring 
in children reported in the literature. Their case is a white female in- 
fant prematurely born 8 April 191*1*, weighing 3 pounds, l£ ounces. She was 
kept in an incubator for one month, and when removed had a small, hard, ir- 
regular area over the left breast. At the age of five months, a reddened, 
non-tender lump was noted at the tip of the left second finger. This was 
treated with hot packs. A month or so later, a small mass was noted in 
the left axilla. "At seven months raised areas suddenly appeared on the 
left forearm and on the dorsum of the left hand and continued to enlarge 
very slowly. At 18 months of age a particle of calcareous deposit was re- 
moved from the left second finger." This recurred. At 2 and 3/1* years, 
a particle was spontaneously extruded from the distal end of the left mid- 
dle finger. "At three years, 5 months, a small lump was noted in the scalp 
at the crown of the head." 
At age of 3-1/2, she was brought to the Children's Orthopedic Hospital, 
Seattle, Washington. X-rays showed calcification in the soft tissues of 
left axilla, arm, forearm, hand and fingers, and an "irregular destructive 
process at the distal end of the with some periosteal reaction." "Masses 
were removed from the left hand, forearm, upper arm, axillary fold, and 
chest wall. Some of the masses were intracutaneous and others were in the 
subcutaneous tissue and were freely moveable. Some were firmly attached to 
bone, and some were within muscle or muscle sheaths. The masses were ir- 
regular, white, and varied in size and thickness. The distal joint of the 
middle finger was immobile with stony-hard, subcutaneous masses firmly at- 
tached to the skin and bone at the site of previous partial excision." 
Post-operative course was uneventful. Microscopic examination showed ma- 
ture bone situated in the dermis, subcutaneous tissue, fascia and within 
muscle. "This bone possessed recognizable Haversian systems and centrally 
placed islands of well-formed red and fatty marrow. There were no inclu- 
sions of cartilage but small areas of osteoid at the periphery of the 
plaques where there were narrow mantles of fibrous tissue." The picture 
suggested congenital or developmental origin of aberrant bone. 
Anesthesia in Orthopedics 
Betcher (1*) presents the use of Intravenous Procaine in a series of 
ninety-two patients. In this group he carried out 1*80 procaine infusions. In a review of the history of usage of procaine it is interesting to note 
that Einhorn first synthesized Procaine in 1905, and since that time it 
has been used for: (1) Trigger areas; (2) Sprains; (3) In the treatment 
of fractures (local); (U) Neuralgia. Beer was the first to use Intra- 
venous Procaine in 1908, however. World War II added Impetus to its usage. 
Leriche in 19i*l* used Procaine for post traumatic pain, osteoporosis, trau 
matic arthritis and in painful amputations. Berthelomy, a French Medical 
Officer utilized it in frostbite and in fractures and dislocations. 
Betcher employed the following techniques 0.1 to 0,2 gram of Procaine 
hydrochloride is dissolved in 500-1000 cubic centimeters of saline or glu- 
cose in distilled water. The procaine is administered in 10-50 drops per 
minute for the first ten minutes then 90-150 drops per minute until a re- 
lief of pain was obtained or toxic symptoms appeared. A usual dosage of 
four milligrams per kilogram of body weight was given. Initially sodium 
pentobarbital in .05-.1 gram was given prophylactically in order to re- 
duce reactions but finally the authors abandoned this and merely kept it 
on hand. The typical reaction following intravenous administration of Pro- 
caine consisted of warmth, flush and a taste of a bitter metallic sub- 
stance. Some patients experience nausea and dizziness and one patient 
presented swelling of the extremities and itching which responded well 
to Pyrabenzamine. There were no significant changes in pulse, blood 
pressure or respirations. The Intravenous technique was used in the fol- 
lowing conditions with results as listed; each patient receiving at least 
two infusions and one patient sixteen infusions: 
Condition 
Results 
1. Osteo-arthritis 
Relief of pain and increase 
in range of motion 
2. Rheumatoid Arthritis 
No worthwhile effects 
3* Traumatic Arthritis 
Relief of pain with increased 
mobility 
Bursitis 
Some relief of pain with increased 
motion 
5. Fractures 
Relief of pain 
6, Phantom Pain 
Dulling of pain 
7. Low Back Derangements 
Variable. No effect in Disc 
Radiculitis 
8* Muscular Spasm 
Marked improvement 
9. Congenital Spastics 
Feeling of well being 
10, Anterior Polio (old) 
Feeling of relief 
11. Intractable Pain (Bony Ca 
Relief of pain, diminution of 
Metastatic) 
narcotics 
12. Skeletal Pain of Question- 
able Etiology 
Questionable 
13. Pain, Postoperative, old 
Temporary relief 
Hi• Pain, Postoperative, acute 
Relief of pain, decreased 
analgesic necessary 
l£. Causalgia 
Questionable 
16. Thrombophlebitis, chronic 
Relief of pain and spasm 
17. Indolent Ulcers 
Increased blood supply with 
some evidence of healing 
18. Reiter*s Disease 
No effect Gordon (5) in addition to using Intravenous procaine for the relief 
of pain advocates its usage 200-500 milligrams toward the conclusion of 
surgery and he states that this frequently makes any further postopera- 
tive sedation unnecessary. He also advocates its usage in: (1) Post- 
operative traumatic dystrophy; (2) Urticaria; (3) Intractible hiccough; 
(U) Herpes zoster. 
Brehm and Clay (6) discuss MCurare as an Adjunct to Anesthesia." 
Curare was popularized in 19U2 by Griffith. Squibb manufactured Intra- 
cos trin and Abbott d-Tubocurare. They bring out the fact that some of 
the confusion relating to dosage has resulted from units and milligrams 
being used interchangeably, when in reality they are not similar. They 
prefer the usage of curare, pentothal and nitrous oxide simultaneously. 
They list Myasthenia gravis as a contraindication for its usage and stress 
that facilities for respiration be convenient. 
Sankey, Burdell and Campbell (7) in an article on "Various Anesthe- 
tics in Orthopedic Surgery" discuss the use of the various anesthetics 
commonly employed. Regarding Vinethene or Divinyl Ether they state that 
it has a limited use in Orthopedics and should be used only in those 
cases requiring a short acting anesthetic when profund relaxation is not 
required. It is not usually attended with nausea and vomiting upon re- 
covery and it permits almost immediate ambulation. They do not administer 
Vinethene for procedures requiring more than ten minutes of anesthesia. 
A note of warning is brought out in that Goldsmith and his associates 
have demonstrated liver damage in dogs in procedures lasting more than 
one hour. They bring out the well known fact that Ethyl Ether in use 
now for 103 years is still one of the best anesthetics. They further 
discuss Nitrous oxide in combination with Pentothal and Curare; Cyclo- 
propane, refrigeration in poor risk patients, and Regional anesthetics. 
In their discussion of various anesthetics in Orthopedic Surgery 
they stress the utilization of combinations of anesthetic agents uti- 
lizing the beneficial qualities of several drugs. They conclude with 
the statement that, "Too much emphasis should not be placed on the an- 
esthetic agent because the experience, skill and ability of the admin- 
istrators is a factor of far greater importance than the particular 
agent employed." 
Griggs (8) discusses the homeopathic therapeutics of curare and claims 
positive cures in the following types of cases: (a) post-diphteritic palsy 
with inability to swallow; (b) respiratory failure of bulbo-spinal type 
of poliomyelitis, particularly intercostal type of paralysis; (c) res- 
piratory failure in polioencephalitis. 
Orton (9) gives a brief historical resume of controlled respiration 
and of curare together with a fairly complete description of the commonly 
accepted methods of controlled respiration and a discussion of the mode 
of action of curare and other anesthetic agents. The author believes 
that controlled respiration possesses advantages over voluntary respira- 
tion in thoracic surgery and also in abdominal surgery whenever the res- 
piratory depression is apt to occur. The use of curare produces muscular 
relaxation and abolishes reflexes including the bronchial reflexes and 
allows the use of light anesthesia with its lessened incidence of shock. Zimmerman (10) discusses the use of curare in anesthesia# Over- 
dosage may cause progressive fall in blood pressure, respiratory fail- 
ure, shock, and cerebral anemia. Antidote is prostigmine, l-2cc of a 
1-2,000 solution. Curare is so rapidly eliminated by kidneys that oral 
administration is ineffective. Curare may be used with any general an- 
esthetic agent. Ether requires about l/3 less. Adequate relaxation may 
be obtained with a lighter stage and plane of anesthesia. This improves 
the risk of certain poor risk cases. 
Burke and Linegar (11) made a comparison of the pharmacological ac- 
tion of myanesin and curare in various animals. The effects are similar 
but curare seems to be less toxic than myanesin. The paralyzing action 
of myanesin is due to depression of the central nervous system, reaching 
above the spinal level, and to some slight peripheral or myoneural de- 
pression while that of curare is peripheral, being accomplished without 
significant vasomotor, cardiac, or central nervous system depression. 
Griffith and Cullen (12) found myanesin to be as effective as curare 
in producing selective abdominal relaxation in the ratio of lOcc of my- 
anesin being equal to 20 units of intocostin. No difference was noted 
in the selective action, duration of relaxation, respiratory depression, 
or toxic effects as compared with curare except that myanesin frequently 
produced local thombophlebitis and a transient nystagmus. The authors 
conclude that myanesin is an effective and relatively nontoxic drug but 
that local irritation makes its continued use questionable since it po- 
ssesses no advantages over curare. 
Schlesinger, Drew and Wood (13) studied the clinical uses of myan- 
esin exclusive of its use as an adjuvant to anesthesia* They found a 
2% aqueous solution of the drug used intravenously obviated such toxic 
effects as phlebitis, abcess formation, and hemolysis* Side effects of 
raystagimis, blurring of vision, and circumoral numbness are uniformly 
present when the drug is administered in amounts of to 100 cc of 2% 
solution at the rate of 30 to 1*0 drops per minute, but these are of in- 
terest only in determining clinically the therapeutic levels desired. 
Larger doses or more rapid administration may result in a state simula- 
ting decerebrate rigidity and may also cause cardiac arrest, but the mar- 
gin of safety between therapeutic and toxic doses is much greater than 
with curare. The drug was tested in 123 patients exibiting muscle spasm, 
rigidity, tremor, involuntary movements, acute poliomyelitis, herniated 
nucleus pulposus, acute vertebral dislocations, and Marie-Strumpell ar- 
thritis. In general the drug brought marked relief in all of these con- 
ditions with the chief site of action being in the spinal cord and brain 
stem. It has some hypnotic properties and local anesthetic action, but 
its effect on myoneural functions is minimal. Unfortunately, its effects 
are so evanescent and it is metabolized so rapidly that an effective con- 
centration must be maintained by constant infusion. It is therefore im- 
practical as a therapeutic agent in various spastic conditions, except 
to evaluate muscle spasm and deformities and as an aid in manipulating 
painful contractures and dislocations. Its usefulness in anesthesia was 
not explored in this study. Bone Lengthening 
Allan (Hi) presents an interesting, we11-written article dealing 
with theever present problem of leg length discrepancy. In a summary 
of the Historical Review he covers the work of Codivilla in 1905* who 
forced lengthening under narcoses by traction on the os calcis after 
an oblique osteotomy of the femur. Freiberg and Magnuson used modifi- 
cations of similar methods. Putti in 1921 described a method of trac- 
tion and countertraction and in 1927* Abbott described his method of 
tibial elongation. Some of the common complications encountered with 
these methods were; (1) Overstretching of nerves; (2) Interference 
with the blood supply to the fragments; (3) Insufficiency fixation of 
the fragments. 
Allan states that his indications require that the shortening ex- 
ceed one and one-half inches (lj")« Any degree below this defect can 
be compensated by a pelvic tilt and shoe elevation. He lists the fol- 
lowing contraindications to leg lengthening: 
1. Cases in which there is poor control of the hip and knee joints. 
2. Age, only carried out in adolescents and young adults. 
3. Recent and chronic bone infection. 
In very tall patients in -wham shortening of the opposite extremity 
could be considered. 
5. Faulty nutrition of the short limb. 
His technique consists in utilizing a distracting apparatus modified 
after Haboush and Finkelstein. In forty-seven cases of tibial lengthen- 
ing his average gain in the tibia was two and one-third inches (2 l/3M) 
and the greatest gain four inches. He produces an oblique osteotomy of 
the tibia leaving the periosteum as intact as possible and stressing mini- 
mal soft tissue damage. He avoids complete divisions of the soft tissue. 
The fibula is divided transversely at the same level. 
He presents forty cases of femoral lengthening with an average of one 
and five-eighths inches (1 5/8J) and the greatest gain of three inches. 
The femur presented greater difficulty because of Mtroublesome knee 
stiff ness.11 The reaction of bone to this procedure could be compared 
to that occurring in delayed fracture healing. Muscle responded poorly 
to lengthening with considerable wasting being present. The periosteum, 
membranes and fascia were most resistant to stretching. The blood vessels 
respond to slow stretching (the author stated that he attempted to gain 
one sixteenth inch (l/l6M) daily in distraction) but nerves did not re- 
spond as well. According to his experience the External Popliteal could 
be stretched two inches over a four to six weeks period without losing 
conductivity and a distance of three inches with only temporary impair- 
ment. Joint reactions were not noted about the hip in femoral shortenings 
but the knee joint tended to stiffen. In tibial lengthening the knee was 
usually unaffected. The author submits the following conclusions: 
1. Two inches of lengthening may be gained in the femur and three 
inches of lengthening in the tibia without complications. More 
length can be obtained at the risk of temporary external pop- 
liteal paresis. 2. Lengthening of the tibia and fibula is easier to control 
than femoral lengthening. 
3* Traction with countertraction through bone with complete 
lateral rigidity (casting) are essential to success. 
1*. Certain vascular complication experienced by other surgeons 
are attributable to subperiosteal bone exposure and to di- 
viding the periosteum and fascial structures transversely. 
Histopathology of Synovial Membrane 
Paparella-Treccia and Monticelli (15) discuss the histopathology 
of the synovial membrane under three basic manifestations described by 
Lawen and Biebl: 
1. Infiltrative forms a. Localized (interstitial or peri- 
vascular) 
b. Diffuse (predominantly lymphocy- 
tesplasma cells-leucocytes) 
2» Fibroblastic forms a* Endothelial alterations (prolif- 
erative, cystic, degenerative) 
b. Vascular proliferation 
c. Fibroblastic 
d. Fibrous regression, secondary or 
prinary 
3. The granular form 
The authors state that Lawen1s original work dealt with histological 
analysis of synovitis, meniscus lesions, degenerative arthritis and lues. 
He found fibroblastic degeneration in all conditions* The granular form 
was found only in synovitis and lues. 
The authors describe their findings in biopsies taken from 12 knees 
and ankles in infantile paralysis. The cases are discussed briefly and 
are illustrated by excellent photomicrographs* The authors conclude 
that their most remarkable findings were prevalence of adipose tissue, 
abundance of blood vessels and scantiness of histiocytes. BIBLIOGRAPHY 
1. McLean, G. and Lebo, L. s Multiple calcinosis associated with hyper- 
vitiminosis D., South. M. J., ills 389-39U, May 19i|8 
2. Slocumb, C. H.: Vitamin D toxicity simulating hyperparathyroidism, 
Ann. Rheumat. Dis., 7s l|2-idi, Mar. 19i|8 
3. Edmonds, H. W., Coe, H. E. and Tabrah, F. L. s Bone formation in skin 
and muscle$ localized tissue malformation or heterotopia, J. Pediat., 
33: 618-623, Nov. I9J48 
il. Betcher, A. M.s Use of intravenous procaine in othopaedic conditions. 
Bull. Hosp. Joint Dis., 9s 39-U7, Apr. 19U8 
9. Gordon, R. A.: Intravenous procaine; clinical applications, Canad. M. 
A. J., 99: 93i|-939, Dec. 19U8 
6. Brehm, W. F., and Clay, C. G. s Curare as an adjunct to anesthesia, 
Guthrie Clin. Bull., 18: 29-29, July 19i|8 
7. Sankey, B. D. and Campbell, L. E.: Various anesthetics in orthopedic 
surgery. Am. J. Surg., 79: 817-820, June 19U8 
8. Griggs, V/. B.; Curare with some confirmed symptomatology and horaeo- 
therapeutics, J. Am. Inst. Horaeop., ills H|9, 19l|.8 
9. Orton, R. H.s Controlled respiration and curare in modern surgery, 
Australian and New Zealand J. Surg., 17; 239-2i|6, Apr. 19i|8 
10. Zimmerman, A. J.s Curare in anesthesia and in surgery, J. Am. Inst. 
Horaeop., hi: Iii7-lii9, July 19U8 
11. Burke, J. C., and Linegar, C. R.; Pharmacological studies of myanesin 
and curare. Federation Proc., 7s 208, 19U8 
12. Griffith, H. R. and Cullen, W, G.t Myanesin as muscle relaxant, 
Anesth. and Analg., 27: 232-239, July-Aug. 19l|8 
13. Schlesinger, E. B., Drew, A. L. and Wood, B.s Clinical studies in 
use of myanesin. Am. J. Med., ii; 369-372, Mar. 19l|8 
111. Allan, F. G.; Bone lengthening, J. Bone & Joint Surg., 30B; Ii90-909, 
Aug. 19i|8 
19* Paparella-Treccia, R. and Monticelli, G.: Contribute alia conos- 
cenza della isto-patologia, Ortop. Traumat. App. Motore, 19; 17-26, 
Jan-Mar. 19U8 SUBJECT INDEX 
A 
Acromioclavicular, dislocations, 328, 329 
Adamantinoma, 207 
Albright*s Syndrome, 207, 208 
Amputations, 36i*-367 
cineplastic, 365, 366, 367 
forequarter, 367 
sacroiliac, 367 
spontaneous, 365 
thigh, 367 
tourniquet, 365 
H turn-up-plasty1*, 367 
Anesthesia, curare, UlU, U15 
in orthopaedic surgery, Ulii 
procaine, 1*12, i*H* 
Ankle, arthrodesis, 319 
injuries, 316, 317 
lateral ligaments, tear of, 315 
recurrent dislocation of, 316 
Antireticular cytotoxic serum, (exp,), 391 
Apparatus and new devices, 380, 382 
Arch, anterior (metatarsalgia), 313* 311* 
longitudinal, 311, 312 
Arthritis, 56, 57, 66 
allergic, 67 
atrophic, treatment with diet, 7h 
brucellosis, 6l 
cervical, treatment of, 333 
clinic, 59 
deformans of hip, 72, 78 
gold, distribution, exp., 71 
in treatment of, 71, 7l*, 75' 
incidence, 59 
infectious, 60, 153 
neonatal, 61 
rheumatoid, 61* 
after injury, 61* 
amyloidosis, 66 
cardiac involvement in, 66 
in children, 66 
nodules, 65 
peripheral circulation in, 72 
prothrombin time in, 66 
pulmonary osteoarthropathy, 65 
psychos oraatic, 65 
streptococci agglutination in, 71 
treatment,with transfusions, 72 
by desensitization, 7i* 
comprehensive, 73 
with periostitis of os calcis, 65 Arthritis, Marie-Strumpell, 231, 232 
Arthropathy, diabetic, 70 
neuropathic, 70 
psoriatic, 70 
Aseptic necrosis and Caisson Disease, (exp.) 392 
B 
Back ache, 229> 235, 237 
sciatic syndrome in, 223 
thoracolumbar syndrome in, 275 
treatment of, 276 
Back pain, in lower portion, 219, 220, 221, 228, 233 
due to herniation of fascial fat, 265 
due to narrow intervertebral foramina, 2U0 
gynecologic, 221, 222 
traumatic radiculitis, 230, 231 
treatment, novocaine in, 2U3 
operative aspects of, 259 
operative results in, 2l±5 
Biceps brachii, insertion of, 359 
long head of, rupture of, 332 
Bone and cartilage grafts, (exp.), 389, 390 
Bone calcification, 396 
Bone cyst, 208 
Bone defects, bridging of, 379 
Bone formation and destruction, (exp.), 391 
Bone formation and hormones, 72 
Bone growth, ossification centers in, 20 
retardation of, 20, 21 
Bone growth and development, ('exp.), 387, 388 
Bone healing, (exp.), 390 
Bone lengthening, 1;16 
Bone marrow, puncture for obtaining, 382, 1*00 
Bone metastasis, 206, 207 
Bone opacity, 392 
Bone tumors, diagnosis, 205 
incidence, 205 
pathology in, 205 
sacrum, 212 
surgery in, 205 
vertebral column, 205 
Brachial plexus injury, 331 
Brodie*s Abscess, 1*8 
Bursae, artificial, (exp.), 1*01 
Bursitis, Boxers, 69 
C 
Caisson disease, (exp.), 392 
Calcium metabolism, 396 
Calved disease, 21*2 Carpus, cyst-like lesions, 356 
dislocation, 3U7, 3U8 
excision, 353 
Cartilage, 22, 380 
Causalgia, 137, 138, 139, U*0, 11*1, U*2, U*3 
Cerebral palsy, 131, 132, 133 
Cervical, brachial pain, 335, 336, 338 
discs, 332, 333, 33U 
ribs, 338, 339 
root, 335, 336 
spinal cord injuries, 335 
spine motion, I4.OO 
Chemotherapy, 1*00 
Chest, closure after surgery, 272 
funnel, 271 
stemochondral joints, 272 
wall tumors, 271 
Chondrodystrophy fetalis, 212 
Chondroma, hand, 211 
lumbar spine, 212 
Chondromyxoid fibroma, 211 
Circulation in joints, (exp.), 393 
Clavicle, pseudarthosis of, 332 
Coccyx, painful, 238 
Congenital, absence of bones, 5, 7, 11, 11* 
anomalies and malformations, 5, 9, 11*, 16 
arthrogryposis, 12 
causes of, 8 
club foot and metatarsus varus, 6, 16 
defects, in lower extremity, 9 
deformity, spine, 11, ll* 
dislocation, hip, 1, 2, 3, 1*, 7 
osteodystrophy, condensing, 13 
peripheral nerve paralysis, Erbs palsy, 5 
pseudarthrosis, clavicle, 332 
tibia, 15 
shoulder, 6, 12 
synostosis, 11 
torticollis, 9 
costoclavicular compression, 339 
Coxa plana Disease), 279, 200, 201 
Curare, in paralysis agitans, 126 
in spasticity, 126 
Curare and myanesin in anesthesia, l*li*, i*l5 
D 
Decalcification, electrolytic, 392 
Deformities, after trauma, 196 
Devices, new and apparatus, 371-378* 380, 382 
Disability evaluation, 382 
Dysostosis, metaphyseal, 23 
Dystrophy and pain in extremities, li*i* E 
Elbow, arthroplasty, 355 
contractures, 355 
denervation, 357 
dislocation, 159 
injuries of, 
tennis, 356 
Electric interaction, between nerve fibers, HU* 
Engelmannfs Disease, 13 
Epiphysis, upper femoral slipping, 281-287 
beaded wire in treatment of, 380 
F 
Fibrositis, 68, 226 
Fibrous dysplasia, 207, 208 
Finger, mallet, 3U8, 3h9 
reconstruction, 351 
Forearm, rotation, 35U 
Foot, accessory bones, 317 
dislocation of, 31i*, 315, 320 
flat, 311, 313 
spastic, 312 
injuries of, 316, 317 
postural defects of, 313 
stabilization, 320 
Fractures and/or dislocations, 15)7-195 
acetabulum, 165 
ankle, 176, 177 
calcaneus, 177, 178 
callus pattern in long bones, 187-189 
carpus, 161, 162, 163, 353 
clavicle, 157 
with arm pain, 339 
elbow dislocation, 159 
experimental study of sites of, 187 
external skeletal fixation in, 181, 182 
femur, neck of (hip), 16k, 169, 170, 171, 172, 182 
shaft, 173, 178, 179, 180, 181; 
fibula, dislocation of head, 175 
shaft, 176 
hand, 162, 163 
humerus, 157, 158 
supracondylar, 158 
metatarsal, 177 
parachute jumping, 18? 
patella, 17U, 175 
pelvis, 185 
radius. Colies, 160 
head, 159 
lower epiphysis separation, 161 
radius and ulna, 160, 161 
rib, 185 scapula, 157 
spine, I8i| 
tibia, 175 
treatment of, 186, 187 
compound wounds, 185 
emergency, 186 
minor fractures, 186 
plates in, 183 
screw fixation in, 182 
types of fixation in, 183 
trochanteric, 166, 167, 168, 172 
ulna, 160 
olecranon, 159 
unrecognized, 187 
xiphoid, 185 
Fracture deformities, 196-201; 
treatment of, bone grafts, 198, 199, 200 
raalunion, metacarpal, 198 
ununited, clavicle, 19*J 199 
neck of femur, 201, 202, 
G 
Gas gangrene, (exp.), U00, 1*01 
Gaucher’s disease, 25 
Genu valgum, 303 
Giant cell tumor, 205, 207 
Gout, 69, 70 
Graft, double notch for spine, 379 
H 
Hand, Dupuytren's contracture, 35U> 357> 358 
fibrosis, 3U9 
gangrene, 350 
infection of, 3U9 
injuries of, 3U6, 3U7 
nruscles, innervation of, 357 
posttrauraatic edema in, 350 
reconstruction of, 350, 35l> 352, 35U 
surgery of, 350 
Heberden’s nodes, 69, 358 
Heels, curator, 31U 
painful, 3Hi, 317, 319 
Hemangioendothelioma, 211 
Heterotopic bone formation, U12 
Hip, arthrodesis of, 295-298 
arthroplasty,mold, 292 
evolution of, 291 
study of, 291, 292 
aseptic necrosis in, 293* 29U 
bony ankylosis in, 295 dislocation, pathologic, 288 
traumatic, 289, 290, 291 
lesions of infants and children, 286 
obturator nerve avulsion for pain, 287 
osseous changes in paraplegia, 288 
osteotomy, Leadbetter, 293 
spike, 293 
vacuum phenomenon, 287 
Histamine and muscular spasm, 398 
Homografts, 379 
Hormones and enzyraes, 397* 398 
Hyperostosis, infantile cortical, 21, 22 
I 
Infections, extremities, 52 
Intervertebral disc, complications of surgery in, 257 
rupture in cervical region, 26U 
rupture in lumbar region, 2145-266 
Intervertebral ligaments, 275 
J 
Joint, disease, degenerative, 68 
measurement, 381 
pressure, 1402 
K 
Knee, anatomy, 302 
arthrodesis, positive pressure, 306 
arthroplasty, 306, 30? 
cartilage response to trauma, 306 
cruciate ligaments, 303, 30U 
diagnosis, 302 
fixed extension, 303 
innervation of, 302 
internal derangements of, 30U, 30f> 
meniscectomy, 306 
changes after, 30J> 
meniscus, anatomy, 30? 
calcification, 305 
discoid, 303 
pneumoarthrography of, 302 
popliteal varices, 3OI4 
pyarthrosis, 30U 
synovectomy, 30? 
tibial condyle fracture, 3014. 
treatment of, injuries of, 3014 
surgery in, 30f> L 
Leontiasis ossium, 26 
Leprosy, bone and joint lesions in, 51 
Leukemia, skeletal lesions in, 207 
Lipoid granulomatosis, 212 
Lumbar, disc, 21*1* 
facetectomies, 21*1* 
Lumbosacral spine, pseudoarthrosis after fusion of, 21*0, 21*1 
X-ray study of, 2i*l, 21*2 
Lumbosacroiliac arthrodesis, 21*3 
M 
Malignancy and chemotherapy, k00 
Melorheostosis, 23 
Metabolic studies, 398, 399 
Metals and plastics, 38? 
Motion studies, 1*00 
Multiple sclerosis, 11*9 
Muscle, atrophy, 11*6, li*7 
chest, pain syndrome, 11*8 
disease, ll*5 
dystrophy, ll*6, 151 
palraaris longus, 356 
pretibial necrosis, 316 
relaxants, 125 
Muscle, chemical studies, (exp*), 391* 
histologic studies, (exp*), 393, 39l* 
physical studies, (exp*), 395 
Myalgia, epidemic, ll*8 
Myanesin, 127, 1*15 
in treatment of neuromuscular disorders, 125, 126 
Myasthenia gravis, 131*, 135> 136, 391* 
Myeloma, multiple, 209 
mandible, 209 
Myositis ossificans, 39l* 
progressiva, li* 
N 
Nails, 351* 
Neoplasm simulated by chronic bone lesions, 51 
Nerve, to extensor hallucis longus, 311 
Nerve, median, compression of, 358 
Neuritides, 130, 131 
Neurofibromatosis, 25 
Neuromuscular disorders, physiology of, 121* 
treatment of, pharmacological agents in, 127 
physical medicine in, 11*5 
reeducation in, 150 
Neuropathic joints, 338 
Neuropathy, primary sensory, lk9 0 
Olliers disease, 207 
Osgood-Schlatter*s disease, 26, 27 
Osteitis, acute, 1*3 
Vvawi 4- _ 
pubis, U8, 50 
Osteitis deformans (Paget1s Disease), 29 
Osteitis fibrosa, 208 
Osteoarthritis, 68, 69, 11, 78 
cervical spine, 69 
fingers, 69 
metacarpo-trapezium joints, 35£ 
Osteoarthropathy, 69 
Osteochondroma, 206, 271 
Osteogenesis imperfecta, 10, 15, 27, 28 
Osteoid osteoma, 207 
Osteoma, 207 
Osteomyelitis, acute, 1*1*, 1*5* 1*6, 1*7 
brucellosis, 5>0 
chronic, 50 
antibiotics in, 1*3, 1*1*, 1*5, 1*6 
treatment of, 1*6, 1*7, 
coccidioidal, 50 
face and skull, 1*8, 50 
hematogenous, acute, treatment in, 1*5, 1*6 
hypertrophy of bone in, 1*7 
newborn infant, 1*7 
paratyphoid and typhoid, 1*9 
salmonella, 1*9 
sclerosing, non-suppurative, 1*7 
spine, 1*8, 50, 27I* 
statistics, 1*6 
treatment of, 1*1* 
Osteopetrosis, 22 
Osteopoikilosis, 23 
Osteoporosis, 23, 21*, 25 
Osteotomies, corrective, 378, 379 
P 
Pagetfs disease (osteitis deformans), 29 
Pain and dystrophy in extremities, 11*1* 
Paralysis, acute ascending, ll*7 
serratus anterior, 131 
serratus magnus, li*6 
Paraplegias, treatment of, li*7, 271* 
Pararheumatic diseases, 63 
Patella, chondromalacia of, 305, 30? 
excision of, 307, 380 
Peripheral nerve injuries, 127, 128, 129, 130, 137 
Phantom limb, 36? Phosphatase, 39396, 397 
Physical therapy in arthritis, 80 
Plastic surgery, 380 
Plastics and metals, 387 
Plastocytoma, 209 
Poliomyelitis, 95>, 96, 97, 99, 101 
acute phase of, 97* 101 
case analysis in, 97 
clinical manifestations of, 96, 106, 109 
complement-fixation in, 103 
diagnosis of, 107, 108 
electromyographic studies in, 116, 117 
epidemic, 98, 99, 100 
epidemiology in, 99, 100, 101, 102 
experimental, 102, 10f> 
fatal cases in, 98 
follow-up examinations in, 97 
growth failure in, 113, llli. 
incidence of, 101 
in infant, 109 
medical considerations in, 96 
nerve fiber studies in, 117 
neutralizing antibodies in, 103 
pathogenesis of, 101, 102, 103, 10£ 
pregnancy in, 109 
preparalytic stage of, 97 
recurrent, 108 
sedimentation rate in, 10£, 106 
terminology of, 109 
test for virus in, 102 
treatment of, 109, 110, 111, 112, 113, llli, ll£ 
bulbar. 111 
curare. 111, 112 
muscle, reeducation in, 116 
muscle, transplants in, ll£ 
neurotripsy in, 117 
physiotherapy in, ll£, 116 
reconstruction, ll£ 
thermal antibody, 112 
Polyarthritis, 6l 
Posture, 271 
Prostheses, 368 
R 
Radiation studies, 399 
Radicular pain in upper extremity, 3£7 
Radiographs, 382 
Rehabilitation in arthritis, 80, 81 
Reiter's syndrome, 61, 62 
Rheumatic fever, 63 
Rheumatic lesions, 6$ Rheumatoid disease, 69 
Rheumatism, 97* 99 
aged, 99 
diagnosis, 66 
in pregnancy, 6h 
industrial aspects, 99 
palindromic, 68 
procaine in treatment of, 7U> 79 
psychogenic, 70, 71 
Rickets, 21 
S 
Sarcoidosis, 210 
Sarcoma, bone, 206 
diagnosis of, 209 
Ewing*s, 206 
Paget's disease and, 206 
simulation of, 211 
treatment of, 209, 206 
Sarcoma, synovia, 208 
Scalenus anticus syndrome, 336, 337* 338 
Scalenus medius pain, 338 
Scaphoid fractures, 356 
treatment of, 353* 35U 
Scapula, removal of, 381 
Scheuermann's disease, 272 
Sciatica and sciatic pain, 223, 22U* 229* 235* 238, 260, 26U 
diagnosis of, 229 
neurofibroma of cauda equina in, 237 
spinal fusion in, 235* 236 
Shoulder, anatomy, 32U* 325 
axial projection in, 327 
degenerative lesions of 329* 330 
dropped, 331 
frozen, 330, 331 
painful, 330, 331 
transplants, 332 
dislocation, 328 
fracture, 331 
old, 328 
posterior, 327* 328 
recurrent, 325* 326, 327 
epiphyseal slipping, 332 
girdle syndrome, XU7 
hand syndrome, II4J4, 3h0 
Sickle cell anemia, bone changes in, 29 
Spinal cord injuries, bone disturbances in, 27U 
Spine, anomalies, 271 
fusion of, with screws, 379 
lateral curvature of, (scoliosis), 272, 273 
osteomyelitis of, 27U Spondylitis, ankylosing, 67, 77 
Stellate ganglion block, 378 
Subclavius muscle and neurovascular syndrome, 339 
Supraspinatus tendon, 330 
Suture, delayed for wounds, 378 
Syndactyly, 35U 
Synovioma, 208 
Synovial membrane histopathology, 1*17 
Syphilis, bone, 51 
T 
Tendon, injuries, hand, 353* 356 
repair, 380, 392 
stenosing tendovaginitis, 357 
tenosynovitis of, 350 
transfer, in hand, 352, 353* 35U 
Thumb, movements, 356 
reconstruction, 351, 352, 353 
Tissue healing, tendons, 392 
Toe, hallux valgus, 3UU 
hammer, 319 
Tuberculosis, 33 
antibiotics, 3h 
streptomycin, 3U* 35, 36 
BCG vaccine, 33 
greater trochanter, 38 
hip, 38, 39 
multiple cystic, 39 
nursing in, 33 
rheumatism, 39 
sinuses and abscesses, 35, 39 
spine, 36, 37, 38 
Tumors, malignant, of soft tissues, 212 
V 
Vascular studies, 392, 393 
subclavian vessels, 392 
Vitamin D administration, i;10, i*ll 
Vitamin studies, 398 
W 
Warts, plantar, 317, 318 
Wrist, disorganization, 3h9 
fusion, 35U 
X 
X-ray therapy in arthritis, 76, 79 
Xanthomatosis (Hand-Schttller-Christian disease), 2£, 212 AUTHOR INDEX 
Abercrombie, R. G., 261 
Abramson, A* S., 27^ 
Abt, A. T.t 107 
Ackerman, A.4*. 206, 210 
Acheson, G, H*, 39^ 
Acosta, E,, 51 
Adams, J. C., 31*5. 325 
Adams, J. D., I83 
Adams, R. D., 
Aegerter, B,, 25 
Agerholm, M., U5 
Ainsworth, W. H., 3.87 
Albers, B. A., 67 
Albright, F., 23, J2 
Alexander, E. Jr., 3*57. 395 
Alexander, F., 65 
Allan, F. G., Ul6 
Alldredge, R. H., 3&5 
Allen, A. L., U3 
Allen, L., 377 
Alston, J. M., 35 
Alpem, E. B., 208 
Altavas, R., 365 
Altemeler, W. A., 
Altenberg, A. R., 379 
Alter, M. S., 68, \jS 
Amberson, J. B., 3^ 
Ames, S. R., 151 
Amprino, R., 391 
Anderson, H, C., 33 
Anderson, H. E., y\ 
Anderson, J. C., 163 
Anderson, M#, 
Anderson, R. L., 163 
Ahdreasen, A. T., 14, 158 
Andren, H. E., 1% 
Angerholm, M., 
Annersten, S., 197 
Applegren, A., 67 
Applequist, A., 67 
Applequist, 0., 72 
Appley, A* G., 312 
Arango, 0., l*i, 3*58 
Armer, A. I#, 50 
Armstrong, A. C., 355 
Armstrong, J. R., 289 
Anrola, A«, 97 
Asling, C* W., 397 
Asllng, R,, 185 
Austin, G., 260 
Ayen, 0. C., 35 
Aycock, W. L., 100 
Ayers, W. W., 208 
Ayyar, N. S. N., 196 
Bach, T. F., 57. 59. 60, 6U, 
66. 68, 69. 73. 75. 76. 
91. 233 
Bacslch, P., 391 
Badgley. 0. E., 281, 29*+ 
Bailey, A. A., 131 
Bailey, X. T., 377 
Bailey. J. H., 401 
Baird, 0. L,, 208 
Baker, D. M., J8, 313 
Baker, D. R., 182 
Baker, F., 6 
Baker, D. M., 313 
Baker, Gf S., 209 
Baker, L. B., 231, 297 
Baker, S. L., 390t 27 
Baker, R. T., 209 
Baker, S. L,, 27 
Baker, W. J*, 209 
Bakhsh, A., 256 
Balensweig, I., 60 
Ball, L. H., Mk 
Ball, R. E., 56 
Bang, F. B., 
Barnard, L*, 35^ 
Barnes, R., 114. 335 
Barns, H. H. F., 237 
Barnwell, J. B., 35 
Barr, J. S•, llU 
Barsky, A. J., 351 
Barta, 0* K., 283 
Bartter, F. C., 72 
Basom, W. C.. 51, 372, 378 
Batchelor, J, S*, 81, 339 
*3o: Bateman, J. E., 332, 357 
Bates, J. I., 
Bateson, S., 375 
Bauer, Vf., 53, 73 
Bauman, E., j6 
Bayles. T. B., 73, 75 
Baylin G. J., 210 
Bazliel, I. R., 35^ 
Beal, C, X*, 337 
Beard, E, E,, 69 
Beath, T., 3^ 
Beck, G« S», 66 
Beck, 0., 399 
Becks, h. , 37. 1+7 . 3-97 . 398 
Begg, A. C., 253 
Beerman, C. A., 
Behrend, H. J., 330 
Bell, L. G,, 135 
Bell, L. H., 31^ 
Bellamy, Vf. D., U01 
Beller, A., 212 
Beilis, C. J. 52 
Benians, R. G., 68 
Bennett, A. E., 136 
Bennett, R. L., Ill 
Berg, R., 2J1 
Berger, P. M., 125 
Berkett, G. B. B., 280 
Berman, L. S., 50 
Bernard, Z. A., 353 
Bernstein, L., 286 
Bernstein, S., 35 
Bertrand, J. J., 71 
Betcher, A. M., Ul2 
Betts, R. H., 209 
Bick, E. M., 187 
Bickel, W. H., 36. 33, 293 
Bickers, D. S., 126, 376 
Bikoff, A., 112 
Bingham, J. A. Vf., 367 
Birch, C. A., U9 
Birdsong, M., 39 
Bisgard, J. Vf., 
Black, H. A., 259 
Blackwood, Vf., 335 
Blair, H. C., 365 
Blake, H. E., 352 
Bland, E. P., 273 
Blattner, E. J., 111 
Blazer, A*, 76 
B 1 edin, B., 339 
Block, Vf. D., J1 
Blomgren, E., 
Blosser, J, A., 
Blum, L., 319 
Bock, A. V*, 6^ 
Bodlan, D., 105 
Bogdanovitch, A., 6l 
Bograd, K., 333 
Bohlman, H. R., 377 
Boland, E. Vf., 6H, JO 
Bonnln, J. G., 162.316, 350 
Boone, R. R. Jr,, 376 
Boots, HR., 76 
Borak, J., 76, 79 
Borreelli, P. J., 11 
Bosma, J, P., llj 
Bost, F. C., 1 
Bosworth, B. M., 329 
Bosworth, D. M., iSj, 2U0 
Bonman, H. D., 116 
Bourne, G. H., 396 
Bowden, L,, 205, 206 
Bower, A. G., 7*+ 
Bowman, J. R., 135 
Boyd. H. B., 15. 165, 380 
Boysen, G,, 22h 
Bradford, P. X., 2U5 
Bradley, W. H., 97 
Brallsford, J. ?., 205 
Brain, Vf. R., 269 
Brandt, S., 12 
Brashear, G. B., 368 
Brav, E. A., 315 
Breck, L. W.. 51, 372, 378 
Brehm, Vf. P., hlk 
Briggs, H., 259 
Bringold, A. C., 208 
Brittain, H. A,, 296 
Broadhent, B., 100 
Brock, B, L., 35 
Brockbank, W., 328 
Brodkin, H. A., 271 
Brokaw. 81 Brooke, E*, 208 
Brooks, B. H., 72 
Browder, J*, 
Brown, 6. C.f 101 
Brown, H* J», l6l 
Brown, J. B.# 380 
Brown, R*t 27I+ 
Brown, S. W., 205 
Browne, B«, 4 
Browne, W. B*, 
Brownlee, 0., 34 
Brues, A. M., 399 
Burgsch, H. . 7*+ 
Bruner, J* M*t 352 
Brunner, H., 48, 207 
Bryson, A* F., 288 
Buckman, J • , 1+5 
Buckley, 0. W*, 59. 67 
Bucy, P. C., 333 
Bull, J. W. B., 269 
Bunin, J. J., 60 
Bunnell, $•, 35^ 
Bunts, A. T., 150 
Burke, J* C., 1+15 
Burman, M., 353 
Burnett, C. H*, 399 
Burrows, B. A., 399 
Burrows, H. J*, 176 
Burrus, S. Jr*, 1U6 
Bush, L. F*, 389 
Butler, A. A., 35^ 
Butler, B. B., 221 
Butterworth.R* B., 332 
Buxton, R., JO 
Bywaters, 1. 0. L., 67, 392 
Cady, J* B«, 166 
Caffey, J., 9 
Caldwell, Q. A., 255. 378 
Callaghan, J* J*, 177 
Caloow, A. B., 1+01 
Cameron, C*, 210 
Camp, J. B., 69 
Campbell, M. K., 392 
Canisa, A. P*, 170 
Capener, IT*, 67 
Carlton, C* H*, 163 
Carlton, H. H., 
Carpenter, B. B., 332 
Carroll, Q-. Y ., 371 
Casey, A. E., 96 
Cash, P. T., I36 
Cassell, M. A., 38I 
Casterline, R. F,, 209 
Caughey, J, B*, 96 
Cavallito, C. J., UOI 
Cave, B. I., 37, 30^ 
Chance, 0. Q., lUo, 1*+1+ 
Chandler, F. A., 2§*+ 
Chang, P., 207 
Chanton, B. F., 393 
Chapchal, 0., 388 
Charnley, C. F. W., 306 
Charnley, J., 36^ 
Chayen, M. S., J8 
Chesterman, J, J., 209 
Chlklanco, P. S., 207 
Christie, H. Z., 332 
Ciccone, R., 187 
Clark, B. B., 378 
Clarfc, F. H., 98 
Clarke, M., 10 
Clay, C. 0., klk 
Clemmons, H. M., 157 
Cleveland, M., 167, 186, 2k0 
Cliffton. B. B., 339, 357 
Clough, R, B., 187 
Coe, H. B., *+12 
Cohen, A., 7*+ 
Cohen, S. M., 207 
Cohn. 0. M., 397 
Cohn, M. L*, 3*+ 
Cole, W, H., 110 
Coleman, H. M., 17*+. 307 
Coles, W. C., 266 
Coley, B. L., 205. 206 
Collins, B. A., 397 
Collins, B. H., 66 
Collis, B., 131 
Colonna, P. 0., 3°2, 392 
Colson, &• M., 207 
Commons, R, R., 399 
Conklin, S. B., 28 
Conran, ¥• R., 210 
Constant, C. A,, 211 
Cook, W. C., 238 
Cooksey, R. S,, 115 
Coonse, 0, K., I83 
Cooper, I. S., 126 
Cope, 0., 209 
Cornell, V, H., 206 
Corper, H. J., 3*+ 
Coss, J, A. Jr., 76 
Coventry, M. B., 36, 1+7, 305 
Coverstone, J, C., 59, 212 
Cowan, J. C., 59 
Craft, A. W. J., 367 Craig. J. D., 261, 367 
Crego, C. J. Jr*, 2 
Crisp, B. J,, 262 
Cruise, J. S., 35 
Crutchfield, W. G., 18U 
Culbertson, W. R., 
Cullen, C. H., lUO, lU2, lUH 
Cullen, W. G* 
Cummings, M. C., 399 
Curry, 0. J., 372 
Outhbert, J* B., 352 
Dalgarno, M., 37, 
Dallenmagne, M« J., 388 
Dameshek, V., 382 
Dauer, C. C., 101 
Davis, A. G., 185 
Davis, C. N*, 50 
Davis, D*, 69 
Davis, 0* L., 388 
Dawson, R. L. G., 3U9 
Day, A. J. W., 391 
DeBruyn, P. P, H., 390 
Dedichen, J*, 335 
Dehllnger, K. R., U9 
Delorme, T* L*, ll6 
Delory, G. E., 396 
De Los Santos, 205 
DeMere, M,, 380 
Denham, R. H., 29^ 
Dennison, W. M*, U3 
Denny-Brown, D., 1%, 316 
DePalma, A. P,, 337 
DesMarais, M. H. L., 65, 67 
Dflsopo, N. D., 35 
DeStefano, G. A,, 210 
Detro, J. C., 
DeVito, A. T., 15 
Dewar, P„ P., 162 
Dickson, D. D., 210, 350 
Dickson, P. D,, 97 
Dickson, J. A., 202 
Dickson, R. W., 207 
Diddle, A. W. ,131 
Dill, J. L,. 210 
Dittrich, D., 382 
Doan, 0. A., 399 
Dobson, J., 39 
Dockerty, M. B., 211 
Donald, J. M., 337 
Doesnep.A. A*t 35 
Dorinson, S. M., 381 
Dott, »• M*, 37. 257 
Dotter, W. B., 358 
Douglas, B., 35^ 
Doupe, J*, lUO, lUU 
Douthwaite, A. H«, 58, 67 
Downing, P. H#, 372 
Doyle, J, B., 357 
Draznin, S. Z., 280 
Drsner, M., 101 
Drew, A. L*, 
Drewyer, 0. E., 75 
Dubbs, A. W., jk 
Dugan, H. J*, 109 
Duncan, J, M., 
Dunn, J. H., 59 
Durbin, P. 0., 225 
Bagle, H. R., 3^ 
Baton, L. M., 136 
Eberle, P. S., 368 
Bchlin, P., 
Edmonds, H. W., Ul2 
Edstrom, 0., 66 
Edwards, P. M., 125 
Edwards, W. M., 98 
Eggers, G. W. N., 
Ehrenfeld, E. N., 5-9 
Elam, J. 0., 111 
Elgenmark, 0., 20 
Ellis, J. T., 172 
Eliman, P,, 59. 65 
English, R. H., 263 
Bnneking, W. P., 390 
Enyart, J. L., l6l 
Esquera-Gomez, 0*, 51 
Evans, P. 0., 391 
Brans, H. H., 37, **7. 398 
Byre-Brook, A. L., 325 
Pahlstrom.O. I., 368 
Pairbank, H. A. T., 22, 23, 27 
Pairbanfc.T. J., 305. 331 
Palconer, M. A., 253 
Palo on, W. W,, S-00 
Pan, K., 207 
Pang, H, C,, 65 
Parber, S. M., 3^ Farrow, R. 0., 199 
Fashena, G. J*, 210 
Fauteux, M., 358 
Fay, T., 133 
Feindel, W. H., 275 
Feldman, W* H., 3^ 
Feltner, J, B,, 313 
Ferguson, 0*, 377 
Ferguson, T., 59 
Peuchtwanger, J* L*, 36 
Picai, A., 320 
Fields, A., 333 
Finkier, R. S*, 397 
Fischer, A. E., 122 
Fischer, C. J., 396, 397 
Fischer, F. J., 3U9 
Fischer, K. A., 285 
Fischl, A. A., 210 
Fishbein. W. I., 96 
Fisher, R. G«, 209 
Fitzgerald, F. P., 169, 293 
Fitzgerald, P., 313 
Fletcher, E#, 77 
FIink, B. 1., 396 
Florman, A* L*, 62 
Follia, 0. G., 183 
Forbes, A. P., J2 
Ford, W. J., Jk 
Forster, F, M., 591 
Fosdick, L. S., 
Foster, S. B., 25 
Poster, W. K., 187 
Fourman, L. P. H*, 398 
Fox, K. W., 15 
Fox, M. J. 105, 108 
Fraenkel, G. J., 180 
Francis, T. Jr., 101 
Frankel, C. J., 3 
Freedman, H., 391 
Friedman. H. H., 76, lUU, 3U0 
Freidwald, W, F*, 101 
Freireich, K., 210 
Frenette, U., 320 
Freudenthal, W., 210 
Freyberg, R. H., l6^ 
Irlberg, S., 2>A, 260, 283 
rriedenberg, Z,, 260 
Priedland, C, K., 392 
Friedman, H* H* 78 
Fulcher, 0. H., 373 
Fuller, R. , 21 
Fun-Tong Khoo, 207 
Funsten, R. V,, l6l 
Furlong, M. B,f 9S 
Furste, ¥• L., kOO 
Gale, A. H., 97 
Gallagher, J. R., 185, 3^7 
Gallagher, J, T* F.,-172 
Gallie, W. E,, 319,326 
Gandy, J* R*, 265 
Garber, C. Z,, 389 
Gardner, 1. D., 272, 302, 32U 
Garlepy, R*, 50 
Geckler, B. 0*, 235 
Gelh, M. C., 71 
George, I* L., 165*, 170 
Gervla, W. H., 355 
Geshelln, H,, 69 
Ghormiey, R. K*, Uj, 201,305 
Giannestras, N. J,, 327 
Glannini, M. J., 11 
Gibson. A., 379 
Gifford, H., 109 
Gilbert. J. A., 
Gill, A. B., 2 
Gill. G. G., 351 
Gilmore, C. M., lU6 
Ginde, R. G., 271 
Glick, H., 66 
Godfrey, M. F., 66 
Goetz, F. 0., 273 
Gold. A. M., 317 
Goldberg, D., 163 
Goldenberg, R. R#, J 
Goldfain, B*, 66 
Goldman, J., 7^ 
Goldstein, H. M., 62 
Goldstein, L. A., 315 
Goldstein, N., 112 
Goldstein, R,, 16 
Golseth, J* G., ll6 
Goodman, E. N., 
Gordon, A., 335 
Gordon, B. J,, lU, 22, 30U 
Gordon, M., 63 
Gordon. R. A.. 335, UlU Gordon, S*, 357 
Gordon, S. D., 389 
Gorham, L. W*, 
Gorman, R, D., 
Gosnell, J., ll6 
Gottlieb, I*, 126 
Gould ing, R., 356 
Graham, P. M., kj 
Graham, J. W., 279 
Graham, W, 0., 352 
Granlrer, L. W,, 66 
Granit, R., lUU 
Grant, P. C., 260 
Grantham, B. G,, 2U6 
Graubard, D. J., 78, 118 
Graves, D* A., 11 
Gray, C., 307 
Gray, D, J., 2J2 
Gray, J. B., 5 
Grayson, E. S., 133 
Green, A. F., 3^ 
Green, B., 75 
Green, W. T., 95. 387 
Greenberg, W. B., 11 
Greenfield, J. G., 25 
Greep, R. 0, 396, 397 
Griffith, G. C., 63 
Griffith, H. R., U15 
Griffith, P. R., 70 
Griffiths, D. L., 328 
Grieve, J. W., 66 
Griggs, W. B., klk 
Griswold, R* A., 206 
Grizzard, T. T., 250 
Gryboskl, J. S,, 68 
Gunther, V, A., 372 
Gurd, P. B., 186 
Gurdjian, B. S., 265 
Gurewitsch, A. D., 109 
Guri, J. P., kg, 205 
Guswold, R* A., 206 
Gnyton, A* C., 10^ 
Gwinn, R. P,, 39^ 
Haas, S* L., 20 
Hagemann, P. 0., 69 
Hagey, H., 1 
Haggart, G. E., 338, 357 
Hajdu, N., Ik 
Hakala, E. W,, 159 
Haldeman, K. 0., 306 
Hales, H., 7^ 
Hall, H. D. M., 69 
Halonen, P. I., JO 
Helperin, M* H., 392 
Hamilton, A., 303 
Hamilton, P. !•, 29 
Hammond, G*, 157* l66, l68, 
215, 358 
Hamsa, V. R., 228 
Hanby, J., 317 
Haniech, C. M., 393 
Hansen, A. E., 260, 399 
Hansen, H., 3&8 
Hanson, H. T.t 380 
Hansson, X. 0., 80, lU6 
Hardin, C. A., 351 
Hark, P. W., 325 
Harkness, J,, 59 
Harman, J* W., 393 
Harmon, P, H*, 182 
Harris, H. W.. 30k 
Harris, L* M., 136 
Harris, R* I., Jll 
Harris, V. 0* J., 208 
Harrison, 0. V., 206 
Hart, M. S., 51 
Hartman, T. L., 106 
Harvey, A. M., 395 
Hatcher, C. H*, 205, 211 
Hauser, E. D. W*, 16, 211 
Hauser, H., 358 
Havens, 0. G., 368 
Hawk, G. W., 212 
Hawkins, B. L», 380 
Haythorn, S. R,, 281 
Hays, A» T., Uj 
Headley, H. !•, 6U 
Heald, C. B., 59 
Hedri, E*, 180 
Hedrich, D, W., 173 
Heilhrun, N., 288 
Heimburger, R. E., 333 
Helfet, A. J., 303 * 
Hellenhrandt, P. A., 382 
Helwig, P. 0., 102 
Hench, P, S., 58 
Henderson, M, S., 
Henderson, P, H., 373 Henry, M. 0., 379 
Henschke, U* K*, 368 
Herman, J. W., 39^ 
Heroy, W. Vf., 143 
Herrmann, H., 39^ 
Herschell, W., 37^ 
Herz, J. R., 51* 260, 372 
Heublein, 6. W., 208, 286 
Higginbotham, N. L., 205, 206 
Hill, L. C., 66 
Hilnes. S. H., 361 
Hinchey, J. J., 396 
Hines, H. M., 393 
Hinkle, G. A., 368 
Elpps, H. B,, 377 
Hirsch, C*, 2^3 
Hitchcock, H. H., 331 
Hodes, R., 117 
Hoen, T • I., 126 
Hoff-Jorgensen, B., 21 
Hoffman, B. P*, 27^ 
Hoggarth, B., jk 
Holdsworth, P. V., I85 
Hollenberg, C., Ml 
Hollis, W. J., 393 
Holmes, J*, J8 
Holmes, L. P., 205 
Holoubek, J, E,, 393 
Holscher, E. 0., 257 
Eolsti, 0., 72 
Hood, G. J., 371 
Hopkins, G. S., 212 
Horn, H. A., 109 
Horn, R. 0., 367 
Horstmann, D., 99 
Horwltz, M., 56, JO 
Houghton, J., 209 
Howard, C. R., 377 
Howard, L. D., 35^ 
Howard, R,, 206 
Howarth, M. B., 2J1 
Howie, H., 3US 
Hoyt, W. A., Jr., 379 
Huhenet, B. J., 286 
Hucherson, D. C., 265 
Huddleston, 0. L., Il6 
Huff, P. G., l*+6 
Hughes, B. S. R,, 26, 317 
Hullinghorst, R. L., 109 
Humphries, S. V,, 160, 173 
Hundley, J. M., 2085 
Hunsberger, W. G., 291 
Hurst, W. W.. 210 
Hurt, S. P., 381 
Fuss, J. H., 400 
Hutter, 0. 0*, Jr*, U6 
Ilfeld, P.W., 391 
Illingworth, C. P. W., U6. 365 
Immerman, E. W., jhS 
Imrie, D. T., 375 
Ingelmark, B* B*. *+02 
Ingersoll, R. E., 115 
Ingraham, P. D*, 367 
Inman, 7* T., kOO 
Isaacson, A. S., 281 
Ismael, W. K,, 59 
Ivins, J. C., 201 
Jackson, A. E., 293 
Jackson, £• R,, 395* 396 
Jackson, R., 33^ 
Jacobs, J. E., 275 
Jacobs, L* 6., 162 
Jacobs, S*, 35 
Jaffe, H. L., 211 
Jarvinen, K. H. J., JO 
Jebens, E. H., 6 
Jefferson, 0., 335 
Jerre, T., 287 
Jerry, L., 285 
Johnson, A», 65 
Johnson, 0., 208 
Johnson, L. C., 39^ 
Johnson, M. A. Jr., l6U 
Johnson, R. H., 362 
Johnston, W, W., 396 
Jonas, A. P. Jr., 336 
Jones, A., 97 
Jones, A. E., 6l 
Jones, A. R., 31^ 
Jones, E. D., 392 
Jones, 0, E., UOl 
Jones, H. T., 219 
Jones, H. ¥•, 206 Jones, P. A., 210 
Jonsson, G., 208 
Jorio, 7,, 39 
Joseph, N. R., 393 
Joynt, G. H. C., 205 
Judovich, B. D*, 337 
Juers, B. E., 327 
Kahat, H., 150 
Kalhak, K., 71 
Kanavel, A. B., 350 
Kaplan, A., 237 
Kaplan, B. B., 287, 311, 387, 392 
Karlen, A., 296 
Katz, B., l44 
Katz, T*, 163 
Kauntze, R., l4 
Kauffman, R. R., 210 
Kaye, B. B*, 176 
Keen, W* W*, 137. l40 
Kehoe, J. L,, 109 
Kehoe, M. B., 107 
Kefser, R, P*, 97 
Kelleher, V. H., 99 
Kelly, L. C., 58 
Kelly, M., 64 
Kelso, L« B., 382 
Kemp, 0. R., 393 
Kendridf, J. I., 210 
Keplan, B*, 393 
Kersley, G. P., 70 
Kersley, G. P*, 65 
Kessel, A. V. L., 208, 261 
Kessler, E, H., 315. 3^8 
Kesson, C. M., 24 
Kestler, 0. C., 398 
Key, J. A., 182 
Keyes, B. J., 372 
Khoo, 7., 207 
Kidner, 7. C., 264 
Kidney, J. G., 35 
Klmmelstiel, P., 313 
7. W., 395 
Kincaid, G. 7*, 36 
King, B. B.. 221 
King, B. J., 396 
Kinsella, R. A., 66 
Kirby, C. K., 49 
Kirgis. E. P., 336, 372 
Kirk, B. J., 395. 396 
Klrklin J. *., 353 
Kistler, P. M., SO 
Kitchen, I. P., 160 
Kleinberg, S., 229 
Kleinsasser, L. J., 393 
Klemperer, P., 63 
Klimek, J, V., 401 
Knapp, M. B., 105, ll6 
Knight. G. C.. 269 
Knight. R. A., I33 
Knott. M*, 150 
Knudson, A. B. C,, 376 
Knutsson, 7., 272, 327 
Kobayashi, 0. K., 109 
Kohn, S. E., 108 
Koloeki, B. L., 28 
Korvin, H. G., 279 
Kottke, 7. J*, 116 
Koucky, J. P,, 329 
Kovacs, J., 78 
Kovace, R., IU5 
Krahl,, T. I., 325 
Krehl, W. A., 398 
Kresky, B*, 81 
Krlda, A*, 59 
Kridelbaugh, W. V*, 27 
Krueger. 7. J.# 35. 175. 319 
Kuffler, S. W., 124 
Kuhn. R. A*. 126 
Kurtin. A., 318 
Kurulkar, L. N., 271 
Kuzell, W. C., 67 
Lahirl £• D.. 62 
Lahz, R., 356 
Lamphier, T.A., 5° 
Landsmeer, J, M.7., 325 
Lanfee, M., 176 
Langley, W, P., 209 
Langohr, J. L«, 39^ 
Langston, H. H., 295 
Lapidus, P. W., 207, 311 
Larson, C. B., 331 
Last, R. J*, 302 
Latiolais, S. G., 172 
Lauher, H. 0., 25 
Law, W. A., 81, 291 
Lawrence, J, H., 205 
Leavitt, H. L., 33 
Leho, L., 4l0 Lee, C*. 207 
Lefevre, W. I*, 33° 
Leftwich, W. B., 1*48 
Leggett, B. J., 388 
Lehman, 0., 198 
Lelbolt, F. L., 350 
Llehow, A. A*, *400 
L eke ell, L. . 1*4*4 
Lemesurier, A. B., 298, 326 
L*Bngle, C. S., Jr., 39 
Leonard, Mv H., 316 
Lepine, P. R,, 102 
Lerner, H. H*, 29 
Leslie, M*, 208 
Leslie, W. D., 98 
Leatherman, K. D., 285 
LeVay, D., 333 
Levens, A. S., *400 
Leveuf, J., *4, *4*4 
Levi, D., 338 
Levine, J*, 30*4 
Levy, B. M.# 398 
Levy, D., Jr., 16*4 
Lewen, P., 110 Lewis.O.B., 1?8 
Lexer, E, 35*4 
Lichtenstein, L., 211 
Liehow, A. A,, *400 
Lincoln, E. M., 3*4 
Llndhlom. K., 255, 256 
Lindley, B. L., 69 
Ltnegar, C. R*, *415 
Lipkln, E., 7*4, 79 
Llpman, M. 0*, 78 
Lippmann, R. K., 293 
Lipscomh, P.R., 30*4 
Lissner, H. R., 391 
Litman, N. N., 113 
Little, 0. W. E., 2*42 
Littler, J. Vf., 351. 375 
Livingston, W. K., 1*40 
Loadman, J, B,, 3%. 379 
Lockie, L. M., 73 
Loge, J. P., 382 
Lohman, E., 350 
Loomis, L« K«, 175 
Loopesko, E., 275 
Loos, R., 375 
Loring, H. S., 103 
Loudon, J. B., 3*49 
Lounshury, B. F., 392 
Love, F, M., 210 
Lowheer, L., 5® 
Lowman, 0. L*, 11*4 
Lowry, K. F., 378 
Lucas, L. S., 6 
Lucchesi, M., 63 
Lucchesi, 0., 65 
Luckey, C. A., 210, 35O 
Lugiato, ?• E*, 72- 
Lumb, £• , 209 
Lurje, A., 331 
Lyerly, J. 0., 250 
Mahrey, R. E., 206 
MacDonald, A*, *47 
MacKinnon, W. B., 31** 
MacLaughlin, E,, 35 
MacLean, J. E., 8 
BacNamara, J., 112 
MacMahon, H. E., 25 
Madden, W. J•, 105, 108 
Malkin. S. A. S., 33 
Millineon, F. B., 126 
Mammel, 0. K., 208 
Man, T. F,, de, 21 
Mann, F. C*, 389 
Manning, E. A., 7*4 
Markfcula, R. F., 368 
Marks, J. H., 3*49 
Marple, C. D., 393 
Marsters, R. W., 392 
Martin, A. R., 3*4 
Martin, B., 170 
Martin, C. 0., 38 
Martin, E., 39 
Martin, P. H., 282 
Masland, H. C., I58 
Mason. M. L., 3*46, 3*47 
Mason, R. > 331. 59 
Masters, E. W., 62 
Mathisen, A. K., 36 
Matoth, T., *49 
Matson, D. 0., 387 
Mauch, H,, 36S 
Maurer, E., 210 May, H., 175, 35^ 
Maycock, P. K. Jr., 1U3 
Mayer. J. H., 80, 2jk, 3°7 
Mayer, J., 398 
Mayer, L., 296 
Maxeiner, S. R., 365 
McAlpine, B., 98, 101 
McCarroll, H. R., 3, H3 
McCarter, J. 0., 103 
McCauley, J. C. Jr., 82 
McCutcheon, A., 2^ 
McBonald, B. P., 158 
McDonald, E., 399 
McFarland, B., 11, 307 
McGaw, W. H., 302 
McGeorge, M., 253 
McKelvey,, G. J., kS 
McKelTie. A. M., 389 
McZeown, B. F., 64 
BcKone, B., 33 
McLaughlin, C. R., 
McLaughlin, H. L. 171 
McLean, G., UlO 
McMurray, T. P., 30^ 
Hearns, R. B., 28^ 
Meenen, P. H., 101 
Meirowsky, 3., 29 
Meredith, H. C. Jr., 136 
Mes, G. M., 2U3 
Meschan, I., 302 
Messer, A. A., UOO 
Metcalf, J. W., U5 
Meyer, K., 72 
Meyer, 0., 7^ 
Meyerding, H. W., I30 
Meyers, S. G., 30^ 
Michele, A. A., 35, 159, 175, 3*9 
Middleton, J. W., 69 
Milch, H., 3^8 
Milgram, J. B., 115 
Millar, J. B. C., 367 
Miller, A., 178 
Miller, A. B., 35 
Miller, B. L., 373 
Miller, 3. S., 97 
Miller, J. W., 281 
Milner, I. H., 332 
Milstein, B. B., 3**9 
Miniero. J. B., 3*+9 
Mira, J. J.t U6 
Mitchell, C. L., 173 
Mitchell. S. W., 137, I1*© 
Mclter, H. A., 
Monticelll, G., 
Moon, H. B., 210, 350 
Moor, F. B., 80 
Moore, A. T., 230 
Moore, F. T., 352 
Moore, J. R., 201 
Moore, M. R., 206 
Moore, M. Jr., 30*J-, 328 
Moore, T. R., 2U5 
Moorehouse, G. R., 137* 1^0 
Morgan, L., 11 
Morris, H. B., 3® 
Morris, N., 24 
Morrison, 0. M., 329 
Morse, A., 396 
Morse, L, 21 
Morse, P. W., 36 
Mottershead, S., 336 
Moyer, R. 3., 35 
Mulligan, R. M., 398 
Mxmford, 1. B., 177 
Munro, H. N., 399 
Murray, L. H., 109 
Musgrove, A. H., 127 
Mustard, W. T., 115 
Myers, W. K., 69 
Nach, R. L., 350 
Nachlas, I. W., 9 
Maclerio, E. A., 272 
Naden, J, R., 292 
Nalls, W. L., 35 
Nauta, W. J. H., 32^ 
Neer, C. S., 171 
Nelson, M. M., 37, **7. 398 
Neufeld, A. J., 329 
Neviaser, J. S., 328 
Newcomb, W. J#, 241, 315 Newman, P. H., 358 
Nichol, A. A. M., 59 
Nichole, &• B., 67 
Nicholas, J. S., 39^ 
Nicholson, D. P., J8t 59 
Nieto Cano, C*, 351 
Nissen, K. I., 38, 100, 313 
Nohle, J. A., 276 
Norcross, B. M*, 73 
Norcross, J. R., 37 
Norley, T., 36, 305 
Norwich, I., 310 
Novotny, H., 7^ 
Nunziata, A., 235 
Nygaard, K, K., 356 
Oberhill, H. R., 333 
0*Brien, R, M., U6 
Oldberg, E., 262 
Oldfield, M. C., 35^ 
Olsen, A. K., IU3 
Orhach, B. J*, 376 
Orton. R. He. klk 
Ortved, W. 2., 205 
Osborne, S. L., 80, 116 
Osmond-Clark, H., 327 
Otten, 0., 177 
Paff, 0, H., 3«9 
Page, M. A*, 28 
Palmer, I., 177, 325 
Paparella-Treccia, R*, 3°7< 
Pardee, M. L., 307 
Parker, D, W. L., 290 
Parnell, B., 
Parr, L. J. A., 7^ 
Parsonage, M. J., 
Paul, H. B., 392 
Paul, M. P., 392 
Paul, W. D., 393 
Pautrier, L. M., 210 
Para, J. R., 372 
Peabody, C• W., 305 
Pearson, 0., 316 
Pedersen, H. H., 391 
Pendse, R. D., IU5 
Pehnal, 0. P,, 315 
Penner, L. R., 101 
Perlman, A. W., 15, 22 
Perlman, H.B*, 210 
Perrin, M. Be, 135 
Perry, C* B., 62 
Peterman, 2* A*, 63 
Peters, C. Se, 338 
Pfoutze, I. H., 35 
Phalen, 0. S., 352 
Phelps, W. M., 131 
Phomister. D. B., 197, 205, 356 
Pickard, F, S., 66 
Pilcher, H. S., 3^9 
Pinckney, M. M., 73, ?6 
Pincock, D. P., 372 
Platt, H., 223 
Plewes, L. N., 376 
Pohl, J. P., 113 
Pollack, L. J., 106, 128 
Pomerantz, R. B., 339 
Pomeranz, M. M., U00 
Ponseti, I*, 209, 283 
Poppe, J. K., 271 
Portal, A., 21 
Potter, B. L*, 212 
Potter, J. M., 250 
Pratt, C. H., 38O 
Preston, P, S., U8 
Price, L. W., 65. 209 
Pridle, K. H., Jl4 
Puckey, S., 37, kj 
Pulvertaft, R. 0., 353 
Pyle, M. M., 36 
Quigley, T. B., 30U. 375 
Quintin, T. J., 62 
Racfcmilewitz, M., 392 
Raffel, S., 103 
Ragan, C*, 72 
Railton, S. Y., 3^8 
Rampoldl, A., 7 
Haney, A. A., 258, 33W, 373 
Haney, E. B,, 258. 373 
Hank, B. K., 355 
Rankin, J. 0., 200 
Ransohoff, N. S,, 111 
uuo Rappaport, B., 112 
Ratliff, A. H. C., 
Raven, C. P., 3*5*5 
Raven, R. W., 65 
Read, V. A., 70 
Reed, A. R., 336, 372 
Rees, S. X., 67 
Reeves, R. J*, 210 
Reginster, A., 3^ 
Reiners, 0. R., 3*57 
Relsenman, P. R., 130 
Reissman, S., 212 
Reno, J. H., 182 
Rexed, B., 256 
Reynolds, P. C., Uj 
Richardson, J. X., 327 
Richman, R, M., I87 
Riddel, A. G., 3U9 
Ries, L., 375 
Rlnzler, S, H., 
Riordan, D. 0., 352 
Rise, W. S., 338 
Ripstein, C. B., 157. 35*5 
Riser, W. J, Jr., 209 
Risley, H. A., 151 
Rittenherg, D., 399 
Ritter, H* H., IS 
Ritvo, M*, 69 
Rizzo, P. D., 192> 
Roaf, R., 127 
Robertson, J, X*, 96 
Robertson, J. W., 387 
Robinson, D*, 205 
Robinson, W. D*, J1 
Roche, M. B., 63, 2U3 
Rodholm, A* K., 356 
Rosenberg, D., 112 
Rosenberg, M. L», U8 
Rosenblum, H*, 6U 
Rosenow, X. C., 102 
Rosin, A*, 392 
Ross, D., 20 
Ross, S. T., 212 
Rossignol, J* C., 332 
Routti, 0., 72 
Rowbotham, G. P., 
Robertson, G. W., 
Roy, L. P., 207 
Royster, H. P., 
Rozansky, R*, U9 
Rubin, L. R., 3*57 
Ruch, M. K., 352 
Rugg-Gunn, M. A., 22 
Russell, B., 75. 317 
Russell, 0. D., 375 
Russell, H. S., 68 
Russell, W. R.,97 
Ryan, 0. A., 272 
Ryle, J. C., 100 
Sacasa, C. F., 69 
Sadek, X., 286 
St. Janes, R#, 131 
Salem, X. P., 2U0 
Sallick, M. A., 319 
Salzman, P. A., 207 
Sampson, D. A*, 3***5 
Samson, J. X., 
Samson, A., 285 
Sanchis-Olmos, V., 33 
Sanders, X. M., IU7 
Sandison, C., 
Sante, L. R., 207 
Savage, 0., 59 
Saxton, G. D., 36 
Scanlan, R, L., 69 
Scales, J.T., 375 
Schaefer, J. X., 207 
Schechter. N., lU, 22, 30U 
Schiller, M. A., 396 
Schlesinger, X. B., 127, 
Schlesinger, P, T., 20S, J$0 
Schlaepfer, K., 3*50 
Schmitt, 0. H., lUU 
Schneider, G. T., 136 
Schnute, W. J., 320 
Schorr, S., 212 
Schram, W. R., 3*59 
Schroder, M., 355 
Schroff, J., 210 
Schuknecht, E. P., 210 
Schulenherg, C. A. R., 356 
Schultz, X. C., 18U 
Schulz, M. D., 206 
Schwab, R. S., 116 Schwartz, R. P., 125 
Sohwartzman, J. R», 2 
Scohey, R. R*, 102 
Scott, G. L.# 68 
Scott, J. C,, 
Scott, S*t Ug 
Scott, W* P., 209 
Scuderi, C., 186, 199. 379 
Scudese, Y* A., 273 
Scully, P. J.t 7^ 
Sear, H. R., 13 
Seddon, H. J., Ill, 129 
Seid, B,, 6l 
Self, B, 3., UH 
Senear, P, E., JO 
Sensenig, B. C., 388 
Seth-Smlth, D. W., 66 
Shaher, H., ll6 
Shaffer, J# 0., 70 
Shapiro, L. B*, 65 
Shapiro, R* N., 387 
Shaw, A. B., 185 
Shaw, H* H., 318 
Shaw, R. S., 257 
Shellit0, J. G., 211 
Shaman, I. 0., 395 
Sherman, M. S., 39* 
Sheppard, W. B., 255 
Shipp, P. L., kj 
Shockman, R., 206 
Short, D. W., 211 
Shumacker, H. B. Jr., I37, I38, I39 
Shuman, H. H., 21 
Siegel, S., ll6 
Silherherg, M., 398 
Silberstein, H. B*, UOO 
Silverman, P. N*, 20J 
Simmonde, P* A., 295 
Slmmone, C. C., Ug 
Simpson, N. R. W., J2 
Sims, M. M., 378 
Sinclair, D. C., 275 
Slnherg, S. B., 185 
Singer, K., 280 
Skoglund, C. R., iW- 
Skowlund, H. V., 382 
Slocum, H. 0., klO 
Smedal, M. I., 20J 
Smillie, I. S., 303 
Smith, B., 112 
Smlth-Petersen, M. N,, 291 
Smyth, P* S*, 25 
Snapper, I., 209 
Snethan, H. J*, 
Snow, W. 0., 6j 
Soderherg. B. H., 380 
Sommervllle, B. W., 38 
Soto-Hall, R., 306 
Spear, 0. I., JO 
Speigel, I. J., 138 
Splesman, I. G., 207 
Spinelli, 7. A., *+7 
Spira, B*, 33I 
Spitzer, N., 76, lUH, 3U0 
Spitzer, R., 209 
Sponsel, K. H., 215 
Spray, G. H., 398 
Spriggs, J. B., 181, 263 
Spurling, R. G., 
Stack, J. X,, 353 
Stahl, P., 281 
Stanhury, J* B., 39^ 
Starr, S. B., 317 
Stearns, W, H., 3^ 
Stebbins, 353 
Stecher, R. M., 69. 358 
Steele, J* M*, 66 
Steenken, W. Jr., 35 
Stein, I., 372 
Steinhach, H. B., 39U 
Steinberg, 0. L*, 6l 
Steinhrocker, 0., lUU, 76, 3^0 
Steindler, A., 1 
Steinman, C., 3^9 
Stengel, B*, 80 
Stenhouse, D., 208 
Stevens, A. B., 9 
Stevenson, J* W., l6l 
Stevenson, E, M,, 338 
Stokes, H., 209 
Strange, T. B., 160 
Strauss, B., 100 
Strieker, P. L., 398 
Strickland, E, L,, 368 
Strug, L. H., 159 
Stubbins, S. G., 35^ 
Stuck, W. G., ljkt 229. 289, 
Sugar, S. J., 5° Sulamaa, M.# 
Sulon, B., 37* 
Svartz, N., jk 
Swenson, S. L., 22, 15 8 
Swenson, S. A., 
Sydow, 0. Yon, 21 
Tahrah, 7. L«, M-12 
Tanner, H* A., 103 
Tanzer, R. C., 351 
Taylor, R. A*, 335 
Taylor, J. D., 392 
Taylor, L., 
Tegner, W. S., 73 
Teigen, B. S., 116 
Telford, E. D., 336 
Tenbrinck, M. S., 95 
Terhune, S. R., 375 
Thiele, 0. H*, 238 
Threadglll, 7. D., I38 
Tho, A., 66 
Thomas, 0. 0* Jr., 353 
Thompson, A. R., 376 
Thompson, 7. R., 167, 2U0 
Thompson, J. B. M., 
Thompson, V, P., 391 
Tohlas, C. A., 71 
Tohias, H., 318 
Tobin, W. J.f 375 
Toland. J. J. Ill, 107 
Toone, B. C. Jr., j6 
Torgerson, J., 271 
Tourney, J. W., Hj, 
Townsley, W., 
Traeger, C. W., 226 
Travell, J., l5-S 
Trevor, D., 160 
Troncelliti, B, T., 135 
Trueta, J., 
Trunnell, J. B., l6l 
Tucker, W. E., 313 
Tucker, 7. R., 
Tumulty, P. A*, 
Tureraan, 0. R. Jr., }6S 
Turner, J. W. A., 
Turner, R. H., 1W 
Turner, W. W., 2U3 
Umansky, A. L., 1SU 
Unger, H., 212 
Unger, P. W., 66 
Upjohn, R. H., 132, 13S 
Upshaw, J. B.# 36 
Urlst, M. R., 165, 375 
Ustvedt, H. J., 210 
Valentine, M., 68 
Van Demark, R. B., 353* 3^9 
Van Oorder, 0. W., 169 
Vandmark, W. E., 28 
Van Nee, C. 3&7 
Varadarajan, M. 0., 51 
Vasko, J. R., 367 
Vastine. J. H. II, I1*, 38S 
Vastine, M. 7., l4, 388 
Vaughan-Jackson, 0. J., 356 
Venable, C. S., 37** 
Vergara, S. B., 397 
Vest, S.A., U8 
Viets, H. R., 13^ 
Vlrkkunen, M., j6 
Vitt, R. J., 175 
Vuorl, B, B., U5 
Wade, B, 0., 69 
Wagner, C. J., 198 
Wagner, L. 0., 3°3 
Wagner, M. L., 3&1 
Wahl, S. 168 
Waine, H., 68, 71 
Wakefield, A. R., 355 
Walker, H. G-., 35 
Walker,P. J., 80 
Wallgren, A. J., 33 
Walsh, 7. P., 305 
Ward, 0. B., 377 
Warren, R. 7., 389 
Warren, S., 206 , 208 
Warrick, C. K., 327 
Washburn, S. L., 388 
Waspe, 170 
Watkine,, A. L., 116 
Watkins, M., 318 Watson-Jones, R., 326 
Waugh, G., 77 
Waugh, W. G., 59 
Waugh, R. L., 181, 
Waxraan, A., 69 
Way, 0. B., 26 
Wearer, R. M*, 210 
Weber, R. P., 65, 25 
Webetet, J. B., 265 
Weckesser, B. C., 351 
Weger, A. T., 
Weidenthal, C. M., 109 
Weigner, W. C., 
Weil, I. P., 29 
Weinstein, L., 106 
Weisel, W., 381 
Weiss, P., 395 
Welch, C. S., 
Welch, J. H., 12k 
Wells, J. C., 187 
Wenner, H. A*, 103 
West, B. P., 235 
Westerborn, A., 178 
Whalley, N.. 
Wheat, H. R., 375 
Wheeler, W. B., 98 
Wheelock, M. C., 205 
White, A.R. V., 62 
White, 1. H. , 161 
White, J. 0*, 
White, W. A., 379 
Wiese, H. R., 399 
Widen, A., 325 
H. E., 178 
Wiggers, R. P., 6l 
Wigley, J. E. M., 6l 
Wilbur., R. 0., 
Wilkins. R. W., 392 
Wilkinson, P. R., UU 
Willcox, A., 207 
Willcox, R. R., 6l 
Williams, D. I. G.. 76, 77 
Wlllner, P., 355 
Wilson, C. D., 259 
Wilson, C. L., U01 
Wilson, J. C. Jr., 50, 158 
Wilson, J• L., 111 
Wilson, M* J», 207 
Wilson, W, J., 5 
Wiltberger, B. R., 173 
Windham, S. W., 172 
Windholz, P., 25 
Winkler,, H., 313, l?6 
Winter, B* P., 357 
Wise, 0. S., 393 
Wise, R . A., 367 
Wiseman, TT,, 399 
Wishart, J., 38 
Wissing, B., 209 
Wolfson, S* A,, 68, 378 
Wolgamot, J. C*, 281 
Wolinsky, B., 3^ 
Wolman, B., 5 
Woltman, H. W., 108 
Wood, 0. P., 115 
Wood, P. J., 3lU 
Wood, R. V., Vf7 
Wood, W. 0., 415 
Woodbine, M., 3^ 
Woodruff, J. B. Jr., 210 
Woods, R. P., 395 
Wooley, P. V., 208 
Woolf, D. L., 21 
Wright, C. M. P., 157 
Wright. H. P., 75, 381 
Wright, H. R., 71 
Wright, W. B., 187 
Wulp, G. A., 73 
Wyhurn, 0. M., 391 
Wydro, R. A., 371 
Wyman, A. C., 27 
Wyman, S. M., 209 
Tancey, A, G., 
Ttrehus, 0., 223 
Yontef, R., 3I8 
Young, H. H., 36, 81, 263 
Younger, P., 398 
Zaepfel, P., U7 Zadek, E., 226 
Zadek. I., 220, 317 
Zadick, F. R., 32? 
Zarrow, M. X*, 397 
Zehen, W» Yan, 22 
Zeldenrust, J., J88 
Zimmerman, A. J., U15 
Zuckerbrod, M., 66 
Zuelzer, W. A., 37** 
MV 
GPO 8^-10975