ABSTRACTS of ORTHOPEDIC SURGERY for 1950 OFFICE OF THE SURGEON GENERAL DEPARTMENT OF THE ARMY WASHINGTON, D. C. October 1957 ABSTRACTS OF ORTHOPEDIC SURGERY FOR 1950 Prepared by the Orthopedic Services Of The Medical Departments of the United States Armed Forces Department of Defense PREFACE The completion of these Abstracts of Orthopedic Surgery for 1950 has ■ *'■1*%! —»»■*%■ *%^wwww- been delayed by various causes. Two chapter editors defaulted, another, to the sorrow of us all, had a fatal heart attack before his chapter was completed, and the Editor-in-Chief was transferred overseas where, to say the least, the situation was not conducive to completing the abstracts. Despite the delays arising subsequent to these vicis*situdes, so many men worked so hard and so well to abstract these many articles that there can be no other thought than to publish them, late as they are. Of over 3000 titles obtained from the 1950 Current List of Medical Literature, 1312 have been abstracted. The value of perpetuating this work is believed generally, by civilian and military orthopedists alike, to be .questionable. Many medical Journals, e.g.. Excerpta Medlca, Surgery, Gynecology and Obstetrics, Journal Inter- national College of Surgeons, and others, publish abstracts on a world wide basis. Therefore, with this volume the orthopedists of the Armed Forces bow out. The Editor-in-Chief expresses his gratitude to the men who worked to make this volume possible. f'l • \^K4C^-M>,»»www»w^-*l 7 77 Suction Sockets, 278; General, 278. After Care; Rehabilitation, 279; Nursing Care, 279; Amputations in Malaya and Israeli, 279. CHAPTER XIX Harold S. McBurney, Colonel, MC, USA NEW DEVICES, PROCEDURES, AND APPARATUS. X-ray Techniques; Planigraphy and Differentiation Techniques, 285; X-ray Examination of the Vertebrae, 286; Radiography of the Hip, 286. Devices; X-ray Aids, 287; Surgical Aids, 287; Other Devices, 288. Pr^eclqres; Use of Wires, 289; Diagnostic Procedures, 29O; Relief of Pain, Repair, 291. Apparatus; Splints, Casts, and Supports, 292; Prostheses, 294; Aids for Locomotion, 294. CHAPTER I CONGMITAL DEFORMITIES, GROWTH, AND DEVELOPMENT By William S. Dandridge, Lt. Colonel, U5AP, (MC) Craig Air Force Base, Alabama I. Congenital deformities A. Scope and Incidence B. Etiology C. Systemic anomalies D. Upper extremities E. Head and trunk P. Deformities of the hip 1. Scope and Incidence 2. Pathogenesis 3• Treatment G. Lower extremities II* Growth and development A* Normal growth B, Anthropological aspects C* Experimental work on growth D, Restriction of hone growth Of the 193 titles considered, 76 have been abstracted in this category. Many of the foreign titles are unavailable, and many others sire lacking in meat* Congenital Deformities The scone and Incidence of congenital abnormalities Is presented by MILLER (l) on the basis of a series of consecutive births, 2.2 per cent being found to have either congenital malformations or disease states. Bone malformations In feeble-minded children are reviewed by MAUTNKR (2). Some of the anomalies are reported as occurring In the spine, sacrum, hands, feet, teeth, and fingers. No specific correlations of the anomalies to the type of feeble-mindednesa is attempted except the finger characteristic of Mongo- loids. ECKHOPP (3) mentions a group of common congenital anomalies, none of which can be considered orthopedic with the exception of syndactyly and oth- er hand deformities. It Is felt that the author offers no unusual or inter- esting methods of correction other than the classical descriptions. He states that severe syndactyly requires free grafting. In discussing the etiology of congenital malformations, BROCHIER (k) reports that the majority of abnormalities occur in the presence of one of the following three factors: (a) abnormal position of gravid uterus, (b) abnormal nidus of fetation, or (c) compression deformities of intrauterine origin, l.e*, multiple pregnancy, abnormal membranes, etc* 1 Rubella as a cause of congenital malformations Is the subject of a case report by GALARCON (5), He states that rubella developed in the first month of pregnancy and that the child was born with congenital cataracts and other anomalies# He correlates this case with reports by other authors substantiating the dystrophic actions of the virus of rubella, LANDlPs (6) study of 16 institutional cases of congenital malformations of the postru- he 11a type involves only seven with past histories of maternal rubella, A severe cold is believed to have been the causative factor in five eases and H, influenza in one other. His findings reveal the most common defect in the series to be congenital cataract followed by microcephaly, with a percentage of there patients showing hypotonia spasticity and grand mal seiz- ures. Maternal dietary deficiency is suggested by JEtfTZKR (?) as a possible cause of some of the congenital anomalies in man which do not have a clear genetic origin. He cites the work of Warkany and other investigators who have been able to produce congenital anomalies in animals by giving the fe- male a diet deficient in vitamins during the period of gestation. MASCARBNHAS (8) discusses the incidence, mechanism, and treatment of obstetrical paralysis. In his experience, a brachial paralysis occurs in approximately 0,1 per cent of all deliveries. Recovery is achieved in 50 per cent of the cases although this recovery may not be complete for two years after delivery, (Bis Although obstetrical paralysis is considered a birth Injury rather than a congenital deformity, this article is Included here•) Among the articles on systemic anomalies is a case of osteogenesis im- perfecta congenita occurring in a Hegro presented by SCOTT and W00DIHG (9)* This rare condition has been reported only a few times in Hegroes. A case of Bhlers-Danlos syndrome associated with tetralogy of Ballot is reported by WALLACE and BURKHART (10), Search of the literature fails to reveal previ- ously reported, similar, co-existing syndromes, .An account of renal dysplas- ia in a family with multiple hereditary abnormalities is given by HAWKTHS and SMITH (ll). Clinically, the case is indistinguishable from chronic glo- merulonephritis, The congenital skeletal defects in the family include ar- throdysplasla of the elbows, iliac horns, rudimentary patellae, and dysplas- ia of the fingernails. The authors feel that the renal defects are heredi- tary, as are other abnormalities which Involve both mesodermal and ectoderm- al germ layers. 3RIXBT and BURKS (12) describe a hereditary syndrome consisting of a deformity and luxation of the head of the radius, absence of the patella, posterior iliac spurs, and dystrophy of the fingernails. It is suggested that it be called arthro-onychodysplasia. They describe two eases in one family and cite many similar cases described in the literature, (Bd: It Is interesting to note that one of their described cases died at the age of 26 of "chronic nephritis" since the renal lesions have been described by Hawk- ins and Smith as part of the syndrome. See reference 11,) Two interesting portraits of dwarfs from the collection of JOHN HDHT- 3R (13) are discussed with biographical sketches of the subjects. Among the articles on deformities of the upper extremities is a paper by EMR (1*0 who describes two cases of congenital bilateral subluxatlons of the shoulder Joint* He reports that one case was associated with no other congenital defects and had perfect function in the shoulder Joint, while the other case was associated with numerous other anomalies and had restricted shoulder motion* Congenital posterior stigmata of the shoulders is described by OOHZAL- EZ’-JfBETBSES (15) in his account of three cases of bilateral depression over the humeral head at the tip of the acromion process* He depicts this depres- sion as being funnel-shaped with its base adhering to the osseous surface, and he relates that no other defects in the shoulder were detected by clini- cal or x-ray examination. In one of the cases, the father is reported to have a similar deformity* The author apparently reports these cases in ord- er to find out if any similar cases have been seen by others. An unusual anomaly of the superior extremity in a Tara scan Indian girl is reported by B7AHS et al (16). They give an account of an 11 year old girl with congenital bilateral defects of the radius and an associated hand deformity. Apparently, most of the previously reported cases have been in Europeans. The partial absence is more rare than complete absence and Is more common in males than females. A case report of congenital abnormality of the trapezium and first me- tacarpal bone is published by RHSHPORTH (17). These abnormalities are rare, but the author explains them by presupposing the ossification and persis- tence of one of the minor cartilaginous centers of the trapezium which have been described in the embryo. The first article on deformities of the head and trunk is a case of osteocutaneous defect of the skull presented by TURRETTIHI (18) in which the infant was born of an apparently normal family after an uneventful gestation period. Causative factors are not conclusive except that this is a develop- mental anomaly. Mandlbulo-faclal dysostosis in an year old boy is offered by GAT- HAL (19)* This condition, also known as Franceschettl syndrome, is rare and is characterized by (a) inverse obliquity of the palpebral fissure, (b) at- rophy of the malar bone, (c) atrophy of the inferior maxilla and receding chin, and (d) disappearance of the naso-frontal angle which gives a Mfish- like1* profile. PAIHBAHK (20) gives a detailed discussion of cranio-cleido-dysostosis. Hereditary and familial influences are of importance. Abnormalities of the clavicles and skull are usually present, but other congenital deformities are common; (a) deficient ossification of the pubes, sometimes with complete absence but usually delayed, (b) coxa vara, and (c) abnormalities of the vertebral bodies, ribs, sternum, hands, and feet. The muscles of the should- er girdle are usually normal and the strength of the shoulders is unimpaired. Occasionally pressure on the brachial plexus occurs from the distal fragment of the clavicle. The etiology of funnel chest anomaly, a short central tendon of the diaphragm, is dltcussed by LISTER (21) who has treated cases surgically and who divide# them into those operated upon before the rigid deformity oc- cured and those operated upon when bony deformity is established. In infan- cy* he feels that separation of the xiphoid process with its attachments to the central tendon from the distal sternum is sufficient to release the ster- num and prevent increasing fun ne ling. In adults wedge osteotomies are per- formed on sternum and ribs, the deformity corrected and position maintained by external wire splint. The psychological effects of funnel chest upon children are emphasized and the point is made that because of the long dura- tion of the deformity* the patient is often unaware of his physical 11mltac- tions until after the correction of the deformity, when much increased acti- vity becomes possible, No operative morbidity is reported in hz cases. MALLOWS (22) describes funnel chest as seen in routine military prac- tice* arA finds that in a recent examination of 555 military personnel, the condition was present in per cent. The shallowest depression is given as l/8 inch. No criteria for the diagnosis are given, as to the possible normal variations in shape of the lower throacic cage. Reassurance is the only treatment suggested. The author* in summary* points out that the con- dition is of interest because: (a) "its occurrence brings a little variety to routine medical examinations* (b) it is apparently inherited as a domin- ant characteristic, (c) it may have a significant effect on the position of the heart* and (d) it illustrates the therapeutic value of simple reassurance in appropriate cases •’* MATJTNIE et al (23) by x-raying 80 Mongoloids demonstrate that 37*5 per cent anomalies were found in the lower spine, as compared with five per cent anomalies in the general papulation. There were other congenital malforma- tions, but the preponderance were spinal. The higher instance of spinal de- formity in the younger age group of Mongoloids is attributed to the death of those exhibiting spinal deformities in childhood and adolescence. The Mon- goloid habitus is believed to develop during the sixth to ninth week of fet- al life, at which time the vertebra is formed. Dlastematomyelia is a sagittal division of a segment of the spinal cord or cauda equina as a result of congenital malformations associated with anomalous development of the vertebrae, NEDHATTSEB et al (2h) mention that prior to their study of this anomaly, no cases have been reported in which a diagnosis was made preoperatively. The authors present roentgen criteria which are characteristic of the condition and which may facilitate preoper- ative diagnosis* A case in which the spinous process is deficient and coexists with spina bifida occulta of T-12 is reported by FOTI (25), and TFSCHMDORF (26) discusses static scoliosis in children* There have been articles on deformities of the hip abstracted, A case report of sacral spina bifida and meningocele is discussed by NISSEN (2?) vho shows the importance of general treatment, including bilateral be- low the knee amputation for trophic disturbance of the foot and improvement in the management of urinary Incontinence and returning the patient to so- ciety. Congenital absence of distal segment of the spine is discussed by FREEDMAN (28) in a systematic fashion, including a table of previously re- ported cases. Neurological and visceral abnormalities are discussed, most of which are associated with the early development of the lover spinal nerves. The author's single case is reported of a man of 61 years, with ab- sence of the sacrum and coccyx, distal to the second sacral segment, with atrophy or absent muscles below the knee, life long urinary incontinence, weakness of the anal sphincter and hydronephrosis. The concept that congenital dysplasia of the hip may be the basis for a variety of entities seen in later life is presented by ERLACEER (29)* in- cluding Perthes, slipped epiphyses, and malum coxae senilis. He develops this concept on the basis of x-rays which are not shown in the publication but from which the clinical data are given. He theorizes that these entities are end points of the dysplastlc progression. The importance of early diagnosis of congenital dysplasia of the hip Joint is discussed by HART (30) and its sub-headings, subluxatlon and dislo- cation, are considered from the etlologic point of view. The cardinal signs of congenital dislocation in the newborn are listed and again the importance of treatment, if possible from the day of birth, is emphasized. The Prejka pillow splint is recommended for the earliest cases, and for dislocation in older children, the bilateral plaster splca is used. In infants, treatment is said to take three to six months, if the diagnosis is made in early infan- cy. The Importance of complete treatment before the child learns to walk is explained. Early diagnosis and treatment of congenital dislocation of the hips is also emphasized by PORRBSTER-EROWN (31)* She outlines the clinical findings seen before and after the patient walks and x-ray signs facilitating an ear- ly diagnosis. The "basket splint" and its use in the conservative treatment of this condition is described in detail. Mention is made of surgical treat- ment and its use in the management of irreducible cases. The incidence of congenital dislocation of the hip is surveyed by COR- RIGAN (32) among the Indian population at Island lake, Manitoba and found to be approximately six per cent. He shows ratios of unilateral to bilater- al dislocation of 6:5 and male to female of 1:6,5* The incidence is found to be familial, with blood relationship being shown in all known or suspect- ed cases. A mechanical exploration of congenital dislocated hip, based on avail- able uterine space and fetal position, is given by STORCK (33)* He states that position is not static and represents motion dictated by space and mus- cular pressures of the uterus. The author sets up phases of intrauterine develdpment with rotations. Congenital anteversion of the femur in its anatomical, x-ray, and clin- ical aspects, together with one case as an example, is reported by HAINES (3*0* Open operation for congenital dislocation of the hip is demonstrated by PLATOU (35)* The function and radiographic appearance of the hip are us- ually good in the early years after open reduction, but there is a marked tendency to deterioration 10 to 13 years afterward. 16 case reports of open reduction are presented by INGELRANS and 7AN- LSRBNBERGHE (36) with ages ranging from two to 14 years. These represent 16 open redactions following unsatisfactory closed treatment; no criteria or statistics are included to support the clinical evaluation of satisfactory results* In an evaluation of open versus closed treatment, SCHOLDER (37)» with- out quoting case statistics, advocates closed methods routinely with open treatment in resistant or older (over five) cases* He has followed four cases with "bilateral hip deformities for 15 years. Bone grafting of osteomized femur "by os purum in the surgical reduction of congenital dislocation of the hip Joint in children is described hy STOL (38). Two conveniences in treatment of congenital dislocation of the hip in a child are suggested hy HALL (39)* The first is a canvas deck chair split so as to accomodate a receptacle for urine and feces* In the second, the body portion of a hip splca is removed and the long leg portions of the cast are connected by a V-shaped metal bar. This allows motion in the abduction cast and walking* EXNER (UO) writes on the treatment of congenital dislocation of the hip in infancy without contributing any additional points of interest* Nine other articles on the lower extremities are included. Pigeon toe deformity in children is the subject of an article by SCOTT and HOTTER (*H). Pigeon-toed gait is usually duo to rotation alteration in tibia, sometimes to a deformity of the forefoot, and occasionally to internal fetation defor- mity of the hip. True forefoot deformity (metatarsus varus) should be con- sidered and treated as a clubfoot deformity. The normal average rotation of the tibia in the adult is approximately 20° in a outward direction. Pro- vided no bad posture habits are present to prevent external rotation of the tibia, there are force* active during the daily life of the average child which eventually result in a normal knee-ankle relationship. Several faulty habits are enumerated. Among these are sleeping on the abdomen with the toes pointed inward and sitting in a faulty postural position characteristic of the Japanese in which the feet are turned inward under the buttocks. Di- agnosis of the condition is simple, and the deformity is demonstrated in the standing child by rotating the leg until the patella points directly forward. Treatment by casts and de-rotation as well as corrective exercises are usu- ally unsatisfactory. The authors report excellent results from the use of the Denis-Browne splint. By moans of this splint, worn during sleeping hours, correction (de-rotation) is started gradually, but, as the child becomes ac- customed to the splint, correction may be increased. To avoid knock-knee deformity, the bar separating the feet should not be too long. PAN (**-2) reports a case of congenital hypertrophy of metatarsals and toes involving the second and third metatarsals and phalanges on one foot. He describes his surgical treatment. RICHARDSON in writing on disalignment of the knee, debates the role of rickets in genu valgum, genu varum, and genu recurvatum. The author presents a case of a child with severe bilateral genu valgum deformities due to renal rickets. Genu valgum is also discussed by ROEDERER (*j4) and genu varum by FORREST (^5). An article “by DB VTULP (4-6) and one by SPOTORNO (47) recount the treat- ment of club feet, the latter advocating transplantation of the anterior tibialis to the fifth metatarsus* RICHARDSON (4-8) relates his experience with clubfoot and the importance of correcting the three main components of the deformity in the proper se- quence is emphasized* The author feels strongly that marked ovor-correction should be achieved, preferably in infancy by casts, and he discusses in de- tail his method of achieving results. HART (4-9) discusses clubfeet, concentrating on the treatment by wedg- ing casts* His emphasis is on the order in which deformities are corrected and the technique of applying and maintaining the plaster cast* His method is presented in detail. He favors wedging each cast about two times before changing, and he believes in maintainence of the over corrected position for eight to 12 weeks. The usual follow-up is recommended. Growth and Development On the subject of normal growth, an extensive review of the literature between January 1948 and July 1949 has been made by ZAMECNIE and AUB (50). It deals with studies and recent advances bearing on growth and protein me- tabolism. They divide the review into sections discussing newer methods em- ployed in study of protein metabolism, studies on peptide and protein syn- thesis, amino acid synthesis and interconversions, amino acid transport a- cross the cell membrane, amino acid requirements and the animal protein fac- tor, amino acid antagonists and peptide-like growth inhibitors, tissue cul- ture studies and growth, hormonal relationships to protein metabolism, and neoplasia as related to protein metabolism. The authors cite 192 articles in the bibliography. A report on the significance of growth from the Child Research Coun- cil is presented by WASHBURN (51). GLASER et al (52) report an exhaustive clinical study of 500 premature infants observed in the Cook County Hospital during a two year period. In general, their figures compare with previous studies of this type dealing with full term infants. The slopes of the curves showing growth, lie below, but tend to approach those showing the growth of full term Infants. Negro infants, who make up the majority of patients for this study, show growth curves paralleling, but lying somewhat below those of white Infants. The study was controlled by supplying the parents with free milk and vitamins, and it was felt that when additional foods had to be supplied by the parents toward the age of six months, economic differences in nutrition become a fac- tor. This might explain some of the discrepancies between white and negro children. The articles serve to add basic knowledge to growth studies pre- viously done on full term infants by paralleling those stalles with a des- cription of the growth of permature infants. A rather lengthy article by ROBBINS (53) principally concerns plant or botanical growth, both normal and pathological. It is quite technical con- cerning botany and enlarges the orthopedist’s acumen very little. CHINOY (54) of the University of Delhi, India, reviews his study of growth and development in 260 wheat varieties. The article cannot be recommended to further one*s knowledge of orthopedics. HILDR35TH (55) presents in detail difficulties associated with handed- ness, i.e., speech difficulty. In a second series of articles he presents a detailed manner of overcoming the speech difficulty and other factors by use of mirrow writing and reading, and how to dissociate these factors in retrain- ing handedness. Anthropological aspects of growth are offered hy BUSHRA (56) and SHEP- HERD et al (57)* Studies hy these authors, made of a combined total of 995 adults, present an analytical correlation of a series of measurements of limbs, Jaws, trunk, height, and three space dimensions of the cranium and facial height. Their evidence indicates that relative length of a skeletal part to total body length is linear rather than geometric. The correlation between stature and trunk length is approximately equal in males and females. HALE (58) presents an original article describing the anatomical study intended to quantitate growth of the epidermal ridges of the extremities dur- ing the prenatal period. It was observed that the breadth of the ridges with relation to the size of the extremity is expressed by'a straight line graph. The number of branches of the ridges increases rapidly at first and then becomes constant over a given area at increasing crown-rump length, in- dicating that between a certain point of development, the epidermal ridges do not continue to change in pattern, but only in size. As a measure of maturation, MIIMAH and BAKWIN (59) and GRUELICH (60) point out that the epiphyses of the metacarpals, metatarsals, and phalanges are the most useful centers of ossification for studying bone age under six years• In a paper on temperature Influence over human growth and development, MILLS (6l) quotes statistics which Indicate that a trend has been evident during the last half century toward an increase in the and weight of American boys and girls and toward an earlier onset of the menarche. He finds that this trend was temporarily reversed during the years of 1930-36, and he attributes this to the increased average seasonal temperature during that period. His evidence is not conclusive, however. In experimental work on growth. VIID*E (62) presents data on studies of capabilities of the urodele forelimb primordium to self-differentiato when isolated in vitro in a nutrient culture medium. Results are conclusive that organogenesis of limb buds will occur provided the oxplant has epider- mal covering. Without epidermal covering, the explant develops hlstlotypl- cally. The amount of organogenesis exhibited by the explant is dependent on the stage of development at which the explant is made. Increase in the mass of tissue explanted results in a more mature stage of differentiation in vit- ro. The Influence of growth hormones on growth is the subject of several articles. BE JONGH et al (63) give experimental evidence that growth hor- mones stimulate soft tissue growth and thickening of bones even when longi- tudinal bone growth is prevented. SILBERBERG and SILBERBERG (6*0 report their study of the effects of hormones and nutritional factors on growth, development, and aging of carti- lage and hone. Their findings are based on microscopic changes in the epi- physeal disc. The growth changes show the effects of hormones such as hypo- physeal extracts, thyroid-parathyroid hormone, and estrogenic and androgen- ic hormones on the phases of growth. They also demonstrate the effects of vitamins, low caloric diets, and various other diets upon the growth phases. TAN WAGENEN (65) has been able to double the growth rate and reduce by half the age of the rhesus monkey at the time of menarche by injecting test- osterone propionate, 7*5 milligram per kilogram per week. WEISS and NOBACK (66) conclude from their experiments that the thyroid gland has a role in influencing the time of appearance of the ossification centers of membranes, bones, and primary endochondral bones. An investigation on the relation of their nutritional status to ossi- fication of the bones of children is contributed by NUTRITIONAL REVIEWS (6?) in a series of 162 children ages six to 13 years who were undernourished. Data indicates retarded carpal development to be most marked in boys six to nine years and in girls eight to ten years. The average retardation of bone is 25 months. IRVING (68) discusses the dietary requirements for calcium and cites numerous studies which have been conducted to determine it. Ke concludes that the officially recommended dally allowances are too high and believes that 10 milllgrams/kilogram body weight/day is entirely adequate for an ad- ult man and nonpregnant female. JESSOP (69) discusses nutritional deficiencies occurring in the popu- lation of Ireland, and methods used in obtaining nutritional data, in an ef- fort to break down the statistics in terms of local dietary customs and in- come levels. Several Interesting pecularitles of the Irish diet are brought out, including the scarcity of meat in the rural areas and the absence of any appreciable demand for cheese in Ireland. WETZEL and FARGO (70) record treatment of 11 children with retarded growth with 10 milligrams daily. Five of the patients are reported to have responded dramatically as proven hy a comparable control series. Other noticeable effects are increased vigor and appetite. JANES and MUSG-ROVE (71) report an experimental study on arteriovenous fistulas in dogs and measured the weight and length of the involved extremi- ty after varying lengths of time. Apparently their investigation will have clinical application in the case of patients with retarded hone growth, due to poliomyelitis. In the majority of their animals increased growth was produced in all the long hones of the extremity, and in those which were measured, the temperature of the medullary cavity on the parotid side was greater. This later effect is explained on the basis of increased metabolic activity. It is pointed out that the cardiac effects of arteriovenous fist- ulas at present prohibit their clinical use in increasing growth. Restriction of bone growth by metal pins passed through the epiphyseal cartilaginous plate is demonstrated by HAAS (72) in his experiments upon the restriction of bone growth in rabbits and dogs. The pins are used to fit the epiphysis to the diaphysis, and they effectively stop growth in length on the side of the hone so treated. In some cases, however, there is a com- pensatory longitudinal growth at the uninvolved epiphyseal plate at the op- posite end of the hone. This method has not yet heen tried on the humerus, hut the author feels it may prove of value. A technique hy SPITTLER and BRANNON (73) for Insertion of metal stap- les to cause arrest of epiphyseal growth varies only slightly from the ini- tial paper as given hy Blount, Variations include the use of a temporary guide wire which is checked radiographically. They feel that the perioste- um might he elevated to sink the staples flush with the hone. ARCHIBALD points out that in a group of enuretlc children, radio- logical study reveals a higher incidence of retarded hone age than has heen seen in a controlled series of comparable age. It is pointed out that meth- yl testosterone not only does not tend to accelerate skeletal maturation, hut does seem to give relief of enuresis in those children who have retarded hone age. LEWIS et al (75) report two cases of retarded growth treated with growth hormone prepared hy the Armour Laboratory. In one case dwarfism was associated with osseous retardation and hypoglycemia, and in the other the patient was a cretin, age 1?, taking thyroid and apparently euthyroid at the time of the testing. In both cases nausea and vomiting resulted from the administration of growth hormone and another case has positive nitrogen re- tention or elevation of serum inorganic phosphate. It is felt that in the first case the patient should be abnormally sensitive to small doses of growth hormone. In the second case, because the absence of thyroid activity had been demonstrated, it is felt that any possible catabolic effects of thy- rotrophic contaminants in the serum preparation can be absolutely ruled out. The failure of growth hormone to produce the anticipated effects in human subjects is discussed. The clinical pathologic conference reported in the JOURNAL OF MISSOURI MEDICAL ASSOCIATION (76) deals with the case of a 12 year old girl with a history of rheumatic fever, who entered the hospital seven weeks after an episode of arthritic hone pains, dypsnea, fever, orthopnea, coughing, and bloody sputum. Physical examination revealed distended neck veins, respira- tory distress, hasalar rales and a precordial rough to-and-fro murmur, with pulsating liver edge. The chest x-ray showed bilateral pulmonary infiltra- tion, and this formed the basis of the differential diagnosis, which largely lay between the various members of the so-called collagen group of diseases. Anatomical diagnosis was rheumatic pneumonia, acute rheumatic fever, acute rheumatic heart disease, and congestive heart disease with renal pathology. The article provides an interesting discussion of the pulmonary aspects of the collagen diseases. BIBLIOGRAPHY 1* Miller, H. C.j Scope and incidence of congenital abnormalities. Ped- iatrics, Sprlngf., 5• 320-4, Feb 1950 2. Mautner, H.: Bone malformations in feeble-minded children, Am. J. Ment. Defic., 54: 355-60, Jan 1950 3* Ecldioff, N, L.: Congenital deformities, Guy’s Hosp, Gaz,, Lond,, 64: 211-6, May 20, 1950 4. Brochier, A.! Mechanical factors in the etiology of congenital mal- formations, Pediatrie, 4: 693-702, 1949 5. Galarcon, A, G.j Rubella as a cause of congenital malformations. Am. J. Dis. Child., 78: 914-6, Dec 1949 6. Lande, L.: Congenital malformations with severe damage to the central nervous system due to early fetal virus infection, J. Pediat., S. Lou- is, 36; 625-34. May 1950 7. Jentzer, A.: Congenital malformations, Rev. med. Suisse rom., —5- 14, Nov 1949 8. Mascarenhas, G,: Nonfatal birth injuries; paralysis and fractures; personal cases. Rev. gin. obst., Rio, 44: 398-409* May 195° 9# Scott, R. B,, and Vooding, C. H., Jr.: Osteogenesis imperfecta con- genita; report of a case in a Negro infant, J. Pediat., S. Louis, 36: 381-4, Mar 1950 10. Wallach, B. A., and Burkhart, B. F. J Bhlera-Danlos syndrome associated with the tetralogy of Fallot, Arch. Blochem., 26: 750-2, Apr 1950 11. Hawkins, C. F,, and Smith, 0. B,; Renal dysplasia in a family with multiple hereditary abnormalities including iliac horns. Lancet, 1: 803-8, Apr 29, 1950 12. Brlzey, A. M., Jr., and Burke, R. M.s Arthro-onychodysplasia; heredi- tary syndrome involving deformity of head of radius, absence of patel- las, posterior iliac spurs, dystrophy of finger nails. Am. J. Med., 8: 739-4*4, Juno 1950 13. Hunter's dwarfs, Ann. R. Coll. Surgeons, England, Lond., 6: 446-9, June 1950 14. Fmr, J.: Congenital subluxations of the shoulder Joint, Acta chir. orthop, traum. Cech., 17! 91-6, Mar 1950 15. Gonzalez-Meneses Melendez, A,: Congenital posterior stigmata of the shoulders, Acta pediat. espan., 8: 437-8, Apr 1950 16. Evans, F. G., Alfaro, A., and Alfaro, S.; An unusual anomaly of the superior extremities in a Tarascan Indian girl, Anat. Eec., 106: 37- **7, Jan 1950 17. Rushforth, A, F.r A congenital abnormality of the trapezium and first metacarpal hone, J. Bone Surg., 31 Bs 5**3-6, Nov 19**9 18* Turrottini, A*: Case of a rare congenital malformation; an Infant with an osteocutaneous defect of the skull, Gyn., Basel., 128: **55- 9, Dec 19**9 19* Gayral, Bru: Mandihulo-facial dysostosis (Pranceschetti syndrome), J. radiol. electr., 31: 97-9, 1950 20. Pairhank, H. A. T.: Cranlo-cleido-dysostosis, J. Bone Surg., 31 B: 608-17, Nov 19**9 21. Lester, C. V.: Funnel chest; its cause, effects, and treatment, J. Pediat., S. Louis, 37s 22**-30, Aug 1950 22. Mallows, H. R.: Congenital funnel chest, J. R. Nav. M, Serv., 35* 298-300, Oct 19**-9 23* Mautner, H., Barnes, A., and Curtis, 0.: Abnormal findings on the spine in mongoloids. Am. J. Ment. Deflc., 551 105-7* July 1950 2**. Neuhauser, E. B, D., Wlttenborge, M. H,, and Dehlinger, E.j Diastema- tomyelia; transfixation of the cord or cauda equina with congenital anomalies of the spine. Radiology, 5**: 659-6**, May 1950 25* Potl, M.s The deficiency of the processus sptnosus of the thoracic vertebrae with spina bifida occulta, Radiol. Clin., 19: 185-6, May 1950 26. Tischendorf, R.: Static scoliosis in children, Deut. Gesundhwes, 5* 829-30, June 29, 1950 27* Nissen, K. I.s Sacral spina bifida and meningocele, Proc. R. Soc. M,, Lond., **3j 305, Apr 1950 28. Freedman, B.j Congenital absence of the sacrum and coccyx; report of a case and review of the literature, Brit. J. Surg., 37: 299-303, Jan 1950 29* Erlacher, P.: Dysplasia of the hip joint, Vien. klin. Wschr., 62: 367-70, May 26, 1950 30. Hart, V. L.: Congenital dislocation of the hip in the newborn and in early postnatal life, J. Am. M. Ass., 1**3: 1299-1303* Aug 12, 1950 31. Forrester-Brovm, M.; Early diagnosis and treatment of congenital dis- location of the hips, Med. Press, Lond., 223: 115-20, Feb 8, 1950 32. Corrigan, C., and Segal, S.: The incidence of congenital dislocation of the hip at Island Lake, Manitoba, Canad, M. Ass. J., 62; 535-*!-0, June 1950 33* Storck, H.: Antetorsion, retroversion, and. pathogenesis of disloca- tion of the hip Joint, Zschr. Orthop., 79! 282-94, 1950 Haines, H. S.j Congenital anteversion of the neck of the femur, Ari- zona M., 7: 19-23, Aug 1950 35• Platou, E,; Open operation for congenital dislocation of the hip; re- sults in 54 cases (55 hip Joints), J. Bone Surg., 32 B: 193-202, May 1950 36. Ingelrans, P., and Vanlerenberghe, J.: Surgical treatment of congeni- tal dislocation of the hip in children, Lille chir., 5i 107-9# May- June 1950 37* Scholder, J. C.: Treatment of congenital dislocation of the hip, Zschr. Orthop., 79: 295-305# 1950 38. Stol, J.r Bone grafting of osteomized femur hy os purum in the surg- ical reduction of congenital dislocation of the hip Joint in children, Acta chir. orthop. traum. cech,, 17: 123-34, 1950 39* Hall, R. M.: Two suggestions in treating congenital dislocation of the hip, Austral. IT, Zealand J, Surg., 19t 172, Nov 1949 40. Exner, 0.: Treatment of congenital dislocation of the hip in infancy. Munch, med, Wschr., 92: 589-93# July 21, 1950 41. Scott, W., and Hutter, C. 0.: Orthopedic treatment of the pigeon-toed child, J. Pediat., S, Louis, 37: 243-8, Aug 1950 42. Pan, K. S.; Congenital hypertrophy of metatarsals and toes; report of a case. Chin. M, J., 67: *+50, Aug 1949 43« Richardson, J. L.: Disalignment of the knee, Proc. Hillcrest Mem. Hosp., 6; 122-30, Oct 1949 44. Roederer, C.: Ambulatory treatment of genu valgum in children, Con- cours med., 72: 2421-2, Aug 5# 1950 4$. Forrest, H. J.s Physiologic how legs, Proc. Hillcrest Mem. Hosp., 6: 120-2, Oct 1949 46, De Vulf, A.: Treatment of talipes equinovarus, Acta Ortho. Belg., 16: 98-102, Mar 1950 47, Spotorno, A,: Stabilization of clubfoot after surgery and reduction by transplantation of the anterior tibialis to the 5th metatarsus. Arch, ortop., 63: 98-102, Jan-Mar 1950 46. Richardson, J. L.: The treatment of clubfoot, J. Oklahoma M, Ass., 43; 322-5. July 1950 49* Haft, G. M.: The treatment of cluhfeet with wedging casts, J. Lancet, 70: 252-4, July 1950 50, Zamecnik, ?. C., and Auh, J. C.: Growth, Annual Rev. Physiol., 12: 71-100, 1950 51* Washburn, A. H.: Growth; its significance in medicine viewed as hu- man biology. Pediatrics, 5: 765-70, May 1950 52* Glaser, K., Parmelee, A. H., and Plattner, E. B,: Growth pattern of prematurely born infants. Pediatrics, Springf., 5* 130-44, Jan 1950 53. Robbins, W. J,: Growth; normal and abnormal, Sc. Month,, 692 386- 93, Dec 194-9 54. Ohinoy, J. J.: Correlation between growth and development. Nature, Lond., 164: 879. Nov 19, 1949 55* Hildreth, G.: The development and training of hand dominance; devel- opmental problems associated with handedness, Pedag. Semin., 76: 39- 100, Mar 1950 56. Bushra, E,: Correlations between certain craniofacial measurements, trunk length and stature, Human Biol., 21: 246-56, Dec 1949 57* Shepherd, R, H., Sholl, D. A., and Vizoso, A.: The size relationships subsisting between body length, limbs, and jaws in man, J. Anat., Lond., 83: 296-302, Oct 1949 58. Hale, A. R.: Breadth of epidermal ridges in the human fetus and its relation to the growth of the hand and foot, Anat. Rec., 105: 763-76, Dec 1949 59* Milman, D, H., and Bakwin, H.: Ossification of the metacarpal and metatarsal centers as a measure of maturation, J. Pediat., S, Louis, 36; 617-20, May 1950 60, Greulich, W. W,; The rationale of assessing the developmental status of children from roentgenograms of the hand and wrist, cesk. stomat., 49: 33-44, Dec 1949 61. Mills, C. A,: Temperature influence over human growth and development, Biol, Human Affairs, Lond,, 15: 71-4, Jan 1950 62* Wilde, C, E,, Jr,: Studies on the organogenesis in vitro of the uro- dele limb bud, J, Morph,, 86: 73-113, Jan 1950 63* Jongh, S. S,, do, Paesi, F. J. A., and Wieringen, F,, Van: The influ- ence of growth hormone on the growth of the skeleton and soft tissues of the body. Arch, internet. pharn, dyn., 82: 148-54, Apr 15, 1950 64, Silberberg, M., and Silberberg, R.: Some aspects of the role of hor- monal and nutritional factors in skeletal growth and development. Growth, Worcester, 13 : 359-68, .Dec 1949 65* Van Wagenen, 0.: Accelerated growth with sexual precocity In female monkeys receiving testosterone propionate. Endocrinology, 45: 544-6, Nov 1949 66. Weis, R. M., and Nohack, C. R.: The effects of thyroxin and thioura- cil on the time of appearance of ossification centers of rat fetuses, Endocrinology, 45; 389-95* Oct 1949 6?* Nutritional status and ossification of the hones of children, Nutrit* Rev,, 8: 124-5, Apr 1950 68. Irving, J. T.i The dietary calcium requirements of man, S, Afr. M, J., 24: 601-6, July 22, 1950 69• Jessop, W. J. B.: Common nutritional errors, J. M, Ass. Eire, 2?: 35-41, Sept 1950 70. Wetzel, N, C., and Fargo, W, C.i Growth failure in school children as associated with vitamin B,? deficiency; response to oral therapy. Science, 110: 651-3. Dec 9* 1949 71* Janes, J. M., and Musgrove, J. E. s Effect of arteriovenous fistula on growth of hone; an experimental study, Surg. Clin. N. America, 30s 1191-1200, Aug 1950 72. Haas, S. L.; Restriction of hone growth hy pins through the epiphy- seal cartilaginous plate, J. Bone Surg., 32 A: Apr 1950 73» Spittler, A, V,, and Brannon, E, W,: Technic for insertion of metal staples in cases of epiphyseal growth arrest, Am. J. Surg., 79s 834- 6, June 1950 74. Archibald, R. M,: Frequency of retarded hone age in a group of enur- etic children, J. Clin. Endocr., 10; 833, July 1950 75• Lewie, R. A., Klein, R., and Wilkins, L.: The effect of pituitary growth hormone in dwarfism with osseous retardation and hypoglycemia and in a cretin treated with thyroid, J. Clin. Invest., 29s 460-4, Apr 1950 76. Clinical pathologic conference; rheumatic pneumonia; acute rheumatic fever; acute rheumatic disease, pancarditis, with involvement of the mitral and aortic valves, J, Missouri M, Ass., 47; 675-9, Sept 1950 CHAPTER II DISEASES OF GROWING AND ADULT BONE AND MUSCLES By A, A, Grebe, Colonel, MC U. S, Army Hospital Fort Hood, Texas Assisted By Irwin E, Rosin, Major, USAF, (MC) I. Hereditary bone conditions II. Infectious bone diseases A. Syphilitic conditions B. Echinococcus infections C. Fungus infections III. Met&holic disorders A. Vitamins and their effects B. Rickets IV. Conditions involving hone formation A. Osteitis condensans ilii B. Osteopetrosis C, Osteosclerosis D. Infantile cortical hyperostosis E, Paget*s disease 1. General 2. Laboratory investigations 3. Case reports F, Other conditions V. Conditions involving bone destruction A. Osteoporosis and osteomalacia B, Avascular necrosis C. Conditions involving the nervous system D, Hyperparathyroidism E* Neoplastic bone diseases There are representative articles abstracted for this chapter. Hereditary Bone Conditions Dwarfism is the subject of several articles. A case of dyschondro- plasia (Ollier’s disease) is reported by NARDELL (l) together with several excellent photographs and x-ray reproductions. The case reported presents the characteristic features mostly on one side of the body with hemangiomata more or less confined to the opposite side. As has teen observed in pre- viously reported cases, malignant changes take place. Other cases of Ollier's disease are reported by ROKTA (2) and KIERULP (3), Synonyms for achondroplasia, reports EAIRBANK (4), are chondrodystro- phia foetalis and micromelia. This article gives a complete discussion of achondroplasia which is very well presented. This type of dwarfism is evi- dent at birth in contradistinction to that of chondro-osteodysplasia which is not usually noted for several years. Many cases of achondroplasia die before or soon after birth, but the cases who survive this period usually live in good health for a normal life span. CURTE (5) writes of two cases of follicular atrophoderma and pseudo- pelade associated with chondrodystrophia calcificans congenita, and he re- views the literature of this syndrome which has been observed only in females. A case of dwarfism with total ovarian insufficiency and hypersecretion of gonadotrophic hormone is reported by DE MARCHIN et al (6) consisting of the trial of dwarfism, ovarian agenesis, and a webbed neck with the addition- al findings in this case of epicanthus, nevi, and supernumerary teeth. The administration of estrogens results in an increased feminization in the pa- tient described. It is suggested that the incomplete development of the bones in this disease is due either to a congenital abnormality of the epi- physeal cartilage or to lack of estrogenic factor. -An article on dwarfism by GREEME (7) has no orthopedic significance, and BULGARELLI (8), in four cases of hepatic dwarfism, stresses the clini- cal and biochemical characteristics with particular regard to metabolism of carbohydrates• DUCROQUET and ARVAY (9) report their second case of Morquio's disease, an atypical example in that no kyphosis was present and the muscular liga- ments were not markedly flaccid and loose. A study of 1249 individuals in a single kindred in which facioscapulo- humeral dystrophy occurred is presented by TYLER and STEPHENS (10). There are 58 members of the kindred who manifest the trait described. The clin- ical manifestations of facioscapulo-humeral dystrophy as it occurs in this family consist chiefly of a characteristic pattern and progression in facial, pectoral girdle, and other muscles. The disease is usually benign, only an occasional patient being severely handicapped. A typical Mendelian domi- nant pattern of inheritance with complete penetrance and variable expressiv- ity has been demonstrated. The occurrence of other diseases and traits has been studied in detail, but no significant correlation with progressive mus- cular dystrophy has been found. Infectious Bone Diseases Articles on syphilitic conditions include a case of syphilitic bur- sitis reported by THOMAS and ROOK (ll). Hyperostosis of the clavicle as a symptom of congenital syphilis is given as a historical report by KOZHEV- NIKOV (12). On Echinococcus infections of the bone, DAHDILL (13) cites bis exper- ience with hydatid (Echinococcus) cysts of long hones. He quotes a case of hydatid cyst of the femur necessitating disarticulation of the hip and com- ments that this is usually necessary when the femur is involved. Other long hones may he saved. The author mentions that hydatid cysts of long hones produce radiographic changes that suggest if not define the etiology. WOODLAND (14) and SANTACROCE (15) report cases of echinococcus cysts of hone. The former points out that in five of his cases the vertebral joints were affected, while in another the primary infestation was prohahly in the muscles. The disease is characterized hy extreme chronicity with ahsnece of systemic effects and a high mortality. No pathognomonic radiol- ogic signs are found in this disease. He also states that a diagnosis was made in one case at autopsy, and in the remainder of cases the diagnosis was made following operation at which time hydatid cysts were found in the abscess cavities. Cases of fungus infection are also mentioned. .A case of mycosis fun- go ides with vertebral involvement is reported hy NEWMAN (16) which he treated with nitrogen mustard. It is essentially of dermatological interest with incidental finding of vertebral fracture. Bone involvement in cryptococcosis (torulosis) is reported hy COLLINS (17). Among the diseases of man due to fungus infection, cryptococcosis is best known in the form of meningo-encephalitis. The causative organism, Cryptococcus neoformans, is also termed Cryptococcus hominis, Torula histo- lytica, and several other names which have been applied hy different observ- ers. The organism belongs to the group of fungi imperfecti. Both in tis- sue and in culture, it appears as incapsulated, rounded, hud-ding cells usu- ally five to eight microns in diameter, producing no mycelia or spores. The organisms have freouently been mistaken for lymphocytes or erythrocytes. A characteristic feature of a lesion due to Cryptococcus neoformans is the gelatinous or mucoid character of the exudate. The authors review over 200 reported cases of cryptococcosis which reveal 17 instances of hone involve- ment. Roentgen manifestations of the lesions are not sufficiently charac- teristic for diagnostic purposes. The lesions resemble those due to blas- tomycosis, coccidiodosis, and actinomycosis. The lesions in each of these fungus infections are similar in type and distribution end frequently in- volve joints secondarily. A predilection for tony prominences is noted. Destruction of the bone without periostitis seems to be the rule. The le- sions are chronic, and any change occurs slowly. Regression is apparently possible with reformation of bone of normal structure. Metabolic Disorders One of the publications on vitamins and their effects is an article on chronic poisoning due to excess vitamin A by CARPET (18), Description of the clinical and roentgen manifestations in seven infants and young chil- dren is given. Attention is drawn to the fact that prolonged overdosage of vitamin A administered by misunderstanding, enthusiastic mothers may lead to a toxic state in infants which resembles infantile cortical hyperostes in some ways. The differential diagnosis is discussed, and seven case histor- ies are presented. Complete cure is rapid when vitamin A intake is stopped. Hypersensitivity to vitamin D in transitory renal osteoporosis is dem- onstrated by VAN CREVELD and ARONS (19)* The authors discuss a number of recent investigations on the significance of function of the renal tuhules in the metabolism of phosphorus and calcium. Attention is directed to the hypothesis of Albright according to which vitamin D exerts a primary in- fluence on the excretion of phosphorus by the renal tubules. This is in much the same way as Hunter and Fanconi explain the occurrence of a syndrome which is characterized by dysfunction of the tubules and decalcification of the skeletal system after overdose of vitamin D. The discussion is followed by a description of a patient suffering from a severe form of rickets after three administrations of 300,000 units of vitamin D during the first year of life. Other manifestations of the Fanconi syndrome such as glycosuria, albuminuria, and amino-aciduria are present. Following the administration of diahydrotachysterol a good clinical roentgenological and biochemical im- provement is noticed. The phosphorus balance becomes normal, and important decrease in phosphorus in the urine is seen. The conclusion that the child was hypersensitive to vitamin D is borne out by interchange of the synthetic and the natural vitamin which causes reversal of biochemical changes. The prevention of rickets is discussed by CORNER (20). Rickets is a generalized disorder of metabolism resulting in diminished retention of cal- cium and phosphorus in the body. Owing to the great demand of the rapidly growing skeleton of the 2/oung child for these minerals, any interference with their metabolism will shovr its maximal clinical effect as a disorder of growing bone. Experimental work has conclusively proved that the cause of rickets is deficiency of vitamin D and that normally this vitamin is absorbed from the skin directly into the capillary blood or may be absorbed from the alimentary tract with fat-containing foods. The most important function of vitamin D is to promote the deposition of calcium and phosphorus in bone. In considering the etiology of rickets, the prevention of the disease may be discussed from the following aspects: (a) Treatment during pregnancy and lactation. Pregnancy constitutes a tremendous drain on the maternal stores of calcium. The estimated re- quirement of calcium in the maternal diet during pregnancy is 1.5 grams. Two pints of cow's milk will supply 1,2 grams, and the remainder may be sup- plied by other foods. It is essential to supply adequate vitamin D with the calcium intake, and it is estimated that 800 units daily are desirable. This calcium and vitamin intake should be kept up throughout the period of Lactation. (b) Action of sunlight. Rickets may be prevented by exposure to sun- light or to artificial ultraviolet radiation. Dust, smoke, fog, shadows, etc. all interfere with the contact of the sun's rays with the infant's skin. Whenever temperature permits, the child's whole skin should be grad- ually exposed to sunlight until a good tan is obtained. (c) Dietary measures. Breast feeding has some effect in the preven- tion of rickets. The calcium content of cow's milk is very high, but it requires the addition of vitamin D. When digestive abnormalities are pres- ent, due allowance should be made by giving larger vitamin and calcium sup- plements. Addition of foods particularly for their mineral content early in infant's feeding is an important dietary measure. (d) Vitamin D supplements. It is stated that all normal infants re- quire a vitamin D supplement which should he started at the age of four weeks and continued up to five years. Vitamin D supplement may he supplied hy way of standard cod liver oil or concentrated preparations of vitamin D. (e) Requirements of abnormal infants. Premature infants or small twins require 3000 units of vitamin D daily, and this should he started on the seventh day of life. A child with chronic steatorrhoea has need of large doses of vitamin D and calcium during the period of active growth. Fanconi's syndrome or the association of rickets, glycosuria, hypo- phosphataemia, and mild acidosis, reports KINGSTON (21), is extremely rare. The etiology of the condition is uncertain, hut a hereditary influence is known to exist. It is said to he due to a defect of the renal tuhules which renders incompetent the reahsorptions of glucose, amino acids, and phosphates. This explains the increased amino acids in the urine, the often decreased hlood proteins, and the glycosuria. The defect is said to he in the proxi- mal renal tuhules where glucose and phosphates are normally reahsorhed. The condition being a congenital and often hereditary defect of the renal tuhules, treatment is unfortunately of little avail. BOENIKG (22), MOHRICA (23), and BE GAETANO (24) discuss various as- pects of rickets and various means of treatment. One endeavors to correlate it to juvenile dystrophy of the hones of the foot; another recounts the use of vitamin as a preventive remedy and uses massive doses of vigantol. Conditions Involving Bone Formation Six cases of osteitis condensans ilii are briefly reported hy DDE (25) with reference to the roentgenologic changes in the pelvis and in the dor- sal and lumbar regions of the spine. The author gives the following data pertaining to the patients; five of the individuals were female and the other was male; the age range was from 26 to 66 years; two of the females were single and three were married. His findings reveal all six cases to have changes in the spine consistent with those residual from juvenile epi- physitis and the sequelae of this condition, and three of the cases to have an associated degenerative process in the region of the pubic symphysis. The unilateral condensing osteitis, seen in the youngest patient of this group with evidence of narrowing of the involved sacro-iliac joint, casts doubt on the supposition that condensing osteitis is not associated with joint involvement and might suggest that this contention has been made on the observation of cases with only bilateral involvement where both joints show identical changes. It has been established that epiphyseal growth centers are present during the growth period on the auricular processes of the ilia, although they are not described in all anatomy textbooks. Since the etiology of osteitis condensans ilii is still obscure, the simultaneous presence of this condition with vertebral epiphysitis suggests the possi- bility of a common etiological factor. The immediate impression is that the first condition represents secondary sclerosing changes superimposed on juvenile epiphysitis of the sacro-iliac joints. It would be comparable to the changes which develop in any weight-bearing joint where the joint struc- tures have been altered by a disease process. SEIG-4AN and KILBY (26) report a case of osteopetrosis and review re- cent literature on the subject. The rare and interesting abnormality of osseous development is the "marble bones" first described in by Albers- Schonberg who used that term because of the characteristic dense appearance of the skeletal system. The diagnosis of the disease rests mainly upon the roentgenological findings. It may, however, be recognized clinically by the secondary changes produced, particularly in the more severe forms. Roentgenologically, the bones of the entire skeleton are homogeneously o- paque. The vertebrae, the pelvis, skull, proximal ends of the femurs, and the distal ends of the tibia and fibula are most severely affected. Bone length is usually normal, but clubbing of the ends of the long bones may be noted. In the skull, the suture lines are often wider than normal, the pos- terior clinoid processes are clubbed, and the sella turcica is shallow. The paranasal sinuses and mastoid cells are often not pneumatized or only partially so. Overgrowth of jaw is frequently present. The clinical fea- tures most common are (a) multiple fractures which occur with very slight or even no trauma and which usually heal in a normal time although reports of slow union have been published, (b) optic atrophy, (c) anemia, varying from a mild form to plastic type, (d) lyraphadenopathy, hepatomegalia, and splenomegalia. In the severe form, children affected with this disease usu- ally show a broad face with a wide flat nose, thickened lips, and prominent frontal bosses. Development is generally delayed, particularly with respect to walking, talking, and dentition. Hydrocephalus, deafness, nystagmus, osteomyelitis, and subarachnoid hemorrhages may be seen. The etiology of this condition is not known, but familial occurrences have been so striking that many authors believe the disease is carried in certain family groups as a recessive Mendelian characteristic. Pathologically, this disease is characterized by generally poor vascularization of the skeleton which is be- lieved to be an important factor in the hyperostosis and hypermineralization which are present. In areas of healing fractures, the vascularity and struc- ture of bone approach normal. Blood chemistry studies are usually within normal limits. The differential diagnosis is usually not difficult. The more common diseases which may be confused with osteopetrosis are syphilis, leukemia, tuberculosis, lead, phosphorus, and flourine poisoning, hypervi- taminosis D and A, and Paget's disease. There is no known effective treat- ment for this condition. Prognosis usually depends upon degree of severity. A mild or benign type may be diagnosed quite accidentally. In the more ma- lignant type, death usually results at an early age from intercurrent in- fections, anemia, and hemorrhage. If death does not occur, children with this disease are often marked for life by hydrocephalus, blindness, deaf- ness, and multiple fractures. Generalized osteopetrosis is the diagnosis in a case report by POROT (27). Another case with involvement only of calcaneal epiphyses, bilater- ally, is reported by LACEAPELB (28). Cases of generalized osteosclerosis are reported by PIAZZA (29) and KOHLER and IAUR (30). Infantile cortical hyperostosis is discussed by MacGHEGOR and DAVIES (31). There have been 28 cases of this condition reported. The authors re- port the second case known to have occurred in England. The characteristics of the disease are described as follows. A young infant in good health sud- denly develops a swelling of some part of the body, usually a limb, the face, or the neck. At this stage, there is irritability and sometimes ano- rexia, but constitutional disturbances are slight if any, and the infant usually gains weight normally. The swelling is not hot, and the adjacent skin is not red. X-ray examination shows the formation of periosteal new hone involving a part or the whole of the hone most nearly related to the swelling and also involving some other hones. The hones most commonly af- fected are the mandihle, clavicle, rihs, scapulae, and the long hones of the limhs. Not infrequently, there is some fever and leukocytosis with a nor- mal differential count. The disease is active for from eight weeks to nine months, hut some x-ray changes may persist. The disorder is henign, and all changes eventually disappear without after-effects. Biopsy shows sim- ple hyperplasia of the cortex beneath an actively proliferating periosteum. Cultures are sterile. When swelling and tenderness of the limhs are ac- companied hy localized skeletal appearances which have been described, the lesion may he mistaken for a traumatic or infectious process involving only one hone, and it is probable that cases have been overlooked hy omitting x- ray studies of other parts of the skeleton. BRADLOW and STEINBERG- (32) report two casps of this malady, and LARKIN and ROUSSEAU (33) report another. Paget1s disease* or osteitis deformans, is discussed by JAIRBANK (3*0• It is a chronic disease characterized by slowly spreading changes in one or more of the bones. Changes consist of decalcification combined with osteo- myelitis with replacement of marrow tissue by vascular fibrous tissue. The cause of the disease is unknown. There appears to be a hereditary influence in some cases. The majority of cases are seen after the age of *K) years, and males are more commonly affected than females. The disease may be con- fined to one bone, at least for a period of years. The tibia is a common site for a solitary lesion. Sooner or later, however, several bones are usually affected. Not infrequently, the disease is first discovered as an incidental finding. Approximately only 35 per cent of the patients complain of pain. In advanced cases with many bones affected, a crouching or ”simian" attitude may be noted with the patient in the upright position. Reduction in stature as a result of bowing of the long bones may be considerable. En- largement of the circumference of the skull, kyphosis of the spine, and an- terolateral bowing of the legs are the common deformities noted. The only significant and constant change of the blood chemistry examination is an increase of alkaline phosphatase. Increased excretion of calcium and phos- phorus is also reported, but the amounts have no relation to the severity of the case. The radiographic appearances are quite typical. The bones present a honeycombed or spongy appearance with abnormal striae and areas of increased density or a grossly cystic appearance. The variation in the lesions depends upon the stage of the disease process. In the skull, there is thickening of the outer table and markedly irregular, increased density. The sutures are obliterated, and the coarse mottling presents a picture of the well-known "niggerwool" appearance. Circumscribed areas of bony changes in the skull have been frequently noted. Incomplete fractures are not in- frequently seen, are usually transverse, and tend to heal rapidly. Aside from multiple fractures, the most important well-known complication is de- velopment* of osteogenic sarcoma. The incidence of this latter complication is variously reported as per cent to 11 per cent. Paraplegia, urinary calculus, and multiple myeloma may be listed as rarer complications. In well established cases, the diagnosis is usually not difficult when roent- ography is employed. In the light of two observations, one of a woman with Paget’s disease and the other of a man with a fibro-cystic affection of the hone, BEYSSAC (35) reconsiders the question of fibrous osteitis. Too great an importance must not be attached to osseous fibrosis, as it is merely a common reaction of the osseous tissue, existing in Recklinghausen's and Paget's diseases as well as in a number of other diseases of this tissue. It now seems to be generally conceded that fibrous osteitis is the final stage in marked skel- etal decalcification. The conception of osteoporosis is more restricted in pathological anatomy than in x-ray diagnosis. Biochemical research, although of great interest, may not always help to establish a precise diagnosis. FAUCONNIER and KETELSLBGERS (36) and CZICKELI (37) discuss history, clinical examination, radiological findings, blood chemistry, and histolo- gical changes of Paget's disease. The differentiation from Recklinghausen's disease is shown in table form. Results of microphot©graphic studies of Paget's disease in two cases are given in an account by LASSERRE (38). The following characteristics of the disease are pointed out: (a) destruction of old bone by osteoclasts and (b) formation of new bone by osteoblasts. Both aspects of the process pre- sent a disoriented pattern. The author is of the opinion that one of the cases studied is a premalignant stage of the disease. GOODBODY and ROBERTS (39) investigate basilar invagination in Paget's disease, and SCENEEBERG (40) cites observations on the glucose tolerance test in Paget's disease. The latter states that previous reports of studies of glucose tolerance tests in patients suffering from Paget's disease have indicated abnormalities characterized by high post-absorptive blood levels. Acceleration of the rate of intestinal absorption and disturbances in endo- crine function have been suggested as possible explanations for this varia- tion. The data accumulated from the author's re-study of the problem of glucose tolerance in Paget's disease in patients and in experimental ani- mals fails to demonstrate any significant alteration in patients with os- teitis deformans. In addition to the foregoing, a method of experimentally elevating the serum alkaline phosphatase in dogs is described. Cases of Paget's disease and osteofibroma, each associated with hy- perparathyroidism, are presented by KOCH (41) to stress the importance and value of routine x-ray examination. All of the cases presented show dental manifestations. The author points out that often the earliest symptom of bone disease may be manifest in the jaws and that many of these lesions could be discovered earlier if roentgenographic examinations were more gen- erally used. Other case reports citing various complications of Paget's disease, such as pelvic decalcification, depressed fracture of the skull, bowed ra- dius, and occurrence in siblings, are reported by DE SEZE and ORDONEAU (42), McPEERSON (43), GOD LEW SKI and FALUN (44), 11EYRE (45), and MURPHY (46). The infrequent complication of fractured skull is thought by McPEERSON to be a pathological fracture although trauma sufficient to produce unconsciousness had been sustained. Paget's disease in association with an astrocytoma of the right tem- poral lobe is reported by ESTRIDGE (4?). Although it has been repeatedly reported that the increasing thickness of the skull in Paget*s disease is mainly or entirely outward, the existence of cerebral compression hy ingrowth of the abnormal bona cannot be doubted. While the occurrence of increased intracranial pressure of Paget's disease has not been reported in the liter- ature, the author presents a simultaneous occurrence of Paget's disease with an intracerebral glioma. FLESCH-THEBESIUS (4-8) reports it associated with sarcoma of the maxilla. Material is also contributed on other conditions involving bone form- ation. Three cases of diaphyseal eburnation of the cuboid and one of the tibia, resulting from direct trauma not causing fracture, are reported by LERICHE (**9). The cortical thickening is evidenced on the neighboring bone also. There is marked pain following this eburnation which may recur after vide resection of the bone. The mechanism is unknown. A case of anomalous ossification of ribs as a cause of pseudarthrosis is cited by ASPIN (50). Many anomalies of the upper ribs are found in the course of routine radiography of the chest. In the past five years, several authors have drawn attention to a particular anomaly of the first rib var- iously described as a stress fracture, anomalous development simulating iso- lated fracture, and pseodarthritis. The anomaly presents an irregular trans- verse discontinuity in the middle third of the bony rib. On the radiogram, the exposed ends often show signs suggestive of sclerosis. Frequently, they are bridged by shadows remarkably Ilk© those of callous. It Is suggested that rib pseudarthrosis not due to fracture may develop as an intermediate stage in cases where ossification of the shaft progresses from two centers instead of the more usual primary center near the angle of the rib. A curious case of myositis ossificans blocking the hips is presented by COSTS et al (51). It is that of a female mental patient kept in a straight jacket for six months with myositis ossificans, generalized, but most marked about the hips and elbows. The authors present a long discussion of ectopic bone formation with no new material. Myositis ossificans progressiva is a rare disease of unknown etiology. FRB01AN (52) presents a case report of a 13 year old female who suffered from stiffness for eight years. Early roentgenographlc records suggest an ossifying chondroma at the scapular angle, but later films made eight years after the onset of symptoms show progressive involvement of the erector spi- nae group, the latissimus dorsi, the scapular muscles, and the intercostals. True pulmonary osteoarthropathy and related forms are discussed hy BARIBTT and OOURY (53)• The etiology, clinical picture, and laboratory find- ings are reviewed thoroughly. There are 25 new cases presented. Conditions Involving Rone Destruction There are several articles in this group which concern osteoporosis and osteomalacia. In writing on bone diseases with osteoporotic or malacie changes, COPELAED (5*0 states that diagnosis of the various entities de- scribed is predicated upon a careful work-up of the case, including the his- tory of trauma, pregnancy, lactation, and the menopause. A dietary history considering the intake of calcium, vitamin D, and protein must be obtained. Adequate x-rays of the spine, pelvis, and long bones are frequently indicated. X-rays of the skull should be taken on all bone cases. Blood studies in- cluding calcium, phosphorus, alkaline phosphatase, non-protein-nitrogen, carbon dioxide combining power, total protein, and formol-gsl tests are fre- quently helpful. Special tests, such as acid phosphatase to rule out metas- tases from carcinoma of the prostate, urine for Bence-Jones protein studies, urine tests with Sulkowitch reagent, blood sedimentation tests, and sternal puncture all yield significant findings under appropriate conditions, A routine urinalysis and blood count should never be omitted. Stool tests for fat and other abnormalities are to be done when indicated. In short, a care- ful survey of the patient, with adequate laboratory studies and knowledge of the various causes of osteoporotic and raalacic changes which occur, should be of considerable benefit in solving many problems related to bone atrophy or destruction. SHERMAN (55) presents an excellent historical resume on osteomalacia, an interesting metabolic condition of the skeletal system. She credits Pom- mer with establishing, in 1885, the fact that osteomalacia and rickets are identical. More modern and scientific studies have been done by the workers of the Pieping Union Medical School. Their reports, published in 1925* cov- er most of the phases of the problem. Their findings are as follows. Act- ive osteomalacia is always a manifestation of a negative calcium balance. The urine calcium is markedly decreased or completely absent, and patients derive no benefit from increased calcium intake by mouth. Calcium admin- istered intravenously is followed by calcium retention with improvement of clinical symptoms. This is taken as proof that there is lack of absorption of calcium from the intestinal tract, and, when these patients are given vitamin D or ultraviolet light, symptoms are abolished. It is also seen that true osteomalacia as a deficiency disease has become a great rarity in the western world where diot and hygiene are on a high level. The disease remains common in certain parts of India and China where it mostly affects women, who, due to various social customs, seldom come outdoors or are ex- posed to sunlight. The men and the lower class women who work outside do not have osteomalacia. The etiological factors of osteomalacia are insuf- ficient vitamin D due to a simple lack of this substance in the patients’ diets, or certain gastrointestinal disorders in which the fat-soluble vi- tamin is not absorbed. The renal factor involved may be due to tubular in- sufficiency in which the patients have a decreased ability to excrete acid radicals. Another renal factor is seen in the Panconi syndrome where the constant acidosis is held responsible for the development of defective cal- cification of osteoid tissue. Idiopathic hypocalcuria is also mentioned as a possibility in certain patients who develop a low kidney threshold and continuously excrete a large amount of calcium in urine at the expense of the skeletal system. In addition to the scholarly discussion of this dis- ease, two cases are presented which the author claims to be the fourth and fifth pathologically proven cases of osteo.nalacia to be reported from North America. LEROUX and KERNEIS (56) define osteoporosis and osteomalacia. They present schematically the clinical picture, laboratory findings, and patho- genesis of each disease. Case reports of osteomalacia are contributed by HANSEN (5?) and BERTRAND and SALVAING- (58). The latter’s case is associated with Hanot’s hepatobiliary cirrhosis. In an article on osteoporosis, HOWARD (59) states that generalized tone deficiency is due to metabolic processes of three types, namely, (a) osteoporosis, in which there is inadequate formation of the protein matrix, (h) osteomalacia, in which there is lack of calcium for calcification of hone, and (c) osteitis fihrosa generalisata, in which there is excessive hone resorption. The various causes and clinical sub-types of osteoporosis are presented, important among them being deficiency of the gonadal hor- mones, Post-menopausal osteoporosis, which is the commonest osteopathy en- countered in clinical practice, is discussed at some length. Two case his- tories of this condition are given in detail, and these demonstrate a rapid clinical response to combined estrogen and androgen therapy. Improvement in the radiological abnormalities has not yet been observed. This is ex- plained by the slow rate of calcium retention since eight years would be re- quired to replace a 50 per cent loss of bone calcium. Elevation of serum alkaline phosphatase has likewise not been observed, Nitrogen retention during treatment, which indicates increased protein formation, may account for the symptomatic improvement. KYI'IASTCM (60) discus ses osteoporosis of the spine with spontaneous fracture as a possibility among the numerous causes for backache. This dis- ease is more common in females and usually occurs between the ages of 60 and 70 years. The pain is usually in the lower dorsal or lumbar spine. The on- set may be acute and associated with a fall or sudden vigorous movement, but more frequently it is gradual. Pain is aggravated by activity and relieved by rest. There is occasional radiation of pain around the chest into the abdomen and into the buttocks and thighs. A Kyphos is usually present at the fracture site. Biochemical examinations are usually within normal limits. Diagnosis is usually evident on x-ray studies of the vertebral column. Var- ious other clinical conditions must be excluded, among them spondylitis, Paget's disease, hyperarathyroidism, thyrotoxicosis, osteogenesis imperfecta, Cushing's disease, and Kumraell's disease. Also to be excluded are metasta- tic malignancy, multiple myeloma, and bone changes due to leukemia. The treatment consists of external support of the spine in extension, together with diet supplements of calcium, phosphorus, and vitamin D, RAVAULT et al (6l) report a case of diffuse decalcifying osteosis as- sociated with eunuchism. ARDEN (62) reports an instance of unexplained edema of the right ankle which led to x-ray study in a woman, revealing osteopoikilosis in both feet, hands, hips, and shoulders. He states that there were no other symptoms in this case. In a dissertation on avascular necrosis of tone in children, PEASE (63) discusses the various conditions more normally seen to he the seat of avascular necroses. He is of the opinion that, insofar as local treatment in avascular necroses of the capital femoral epiphysis is concerned, the final outcome of the disease remains the same. Contrary to most orthoped- ists, Pease is of the opinion that braces and splints do not serve any use- ful purpose. He places great stress on the importance of the obturator nerve section in selected cases where abductor spasm is present. AXHAUSM (64) classifies epiphyseal necrosis with slight bone infarcts. PIKE (65) outlines a conservative method of treatment of Legg-Perthe disease, the principal deviation from the generally accepted non-weight hearing regime being prolonged recumbency. There are 29 cases described in which the average length of recumbency was 2? months. The end results are comparable to those of accepted methods of treatment. VAEYE (66) presents four cases, all of different etiologies, of post- traumatic ischemic necrosis of the femoral head to emphasize the necessity for close follow-up in all traumatic incidents to obliviate the diagnosis of aseptic necrosis. If weight is borne before revascularization takes place, deformity and osteoarthritis result. MacDOUGALL et al (67) write of two cases of osteonecrosis of the femoral head occurring in a male and female following extensive irradiation. The literature is reviewed, as well as their own clinical and pathological findings. COMPERE (68) gives a detailed resume of the operative and postoperative techniques in the correction of deformity and prevention of aseptic necrosis in late cases of slipped femoral epiphyses. The joint is approached anter- iorly without stripping the gluteus from the ilium. The capsule is split from the ilium parallel to the neck. A two centimeter wedge is removed from the superior surface of the neck, and the epiphyseal plate is completely re- moved allowing spongy hone to contact spongy hone. When reduced, it is fixed hy three threaded wires. Patients are held in Buck's traction for several days and ambulated on crutches without weight hearing until union is evident, usually about three months. If necrosis is evident, weight hear- ing is postponed until healing is accomplished. SIFFERT and ARKIN (69) report the usual findings of aseptic necrosis following trauma in a part which has not previously been reported to be in- volved in this process. THELANDER (70) describes a case of epiphyseal destruction by frostbite. A case of traumatic premature closure of the subcapital femoral epi- physeal cartilage is cited hy GHORMLEY et al (?l) In a six and one-half year old hoy run over hy a truck resulting in premature closure of the proximal femoral epiphysis. The author reports that there was some compensation over a four year period followed hy a limp due to leverage changes with the shortened neck*. On slipping of the capital femoral epiphysis, SHIMQMEK (72) offers some general remarks but no contribution or cases. WALCH (73)» however, de- picts six cases, of which four were treated by reduction and cast, traction and cast and bone graft, osteotomy, and osteotomy with nailing. He reports that two cases had complications with aseptic necrosis and osteoarthritis. He suggests manipulation and immobilization when the head has not slipped by one-third; when it has slipped over one-third, open reduction with or without fixation is recommended. Coxa vara is discussed by PUJO (7*0, VERBRUGGE (75), IHLMFELDT (76), FURMAIER (77), and PAUWELS (73). The latter three discuss etiology from en- docrinal, hormonal, and mechanical points of view, respectively. Purmaier bases his opinion on about 300 cases, 50 per cent being bilateral, and he recommends conservative rather than surgical treatment even without correc- tion. Pauwels points out that there is a smaller weight bearing surface in coxa ■27- ▼alga. Theoretically, he considers wedge resection of the subtrochanteric region as the treatment of choice and presents three cases treated in this way years previously, Pujo's article is a general and superficial dis- cussion of the subject with no cases and no statistics, while Verbrogge re- counts a study of the epiphyseal plate radlologically and histologically from a case of coxa vara. It shows a lack of development of the cartilage and formation of fibrous tissue. He suggests that traction should, there- fore, be employed for reduction and fixation by a nail. If severe with damage of the head, he .suggests insertion of a prosthesis with reestablish- ment of normal head-neck relations. A paper by MARCOZZI (79) on initial radiographic signs of coxitis in childhood is an analysis of case material with x-rays, and the author gives a discussion of the radi©graphical findings in early inflammation of the joint. He concludes that (a) bone atrophy is more or less diffuse, appears early, and is not diagnostic, (b) separation of the surfaces is Important, (c) the presence of osseous foci is of prime importance, (d) joint surfaces should be changed, (e) distension of the capsule by fluid or granulations may also be present, and (f) special attention should be directed to the changes of the head which frequently correspond in time to the earliest on- set of the disease. A case of arthrokatadysia (intrapelvic protrusion) of the hip joint is reported by HODGKINSON (80). He reviews the literature and presents one case of a year old woman with bilateral protrusion and known restriction of motion since the age of IB years. Etiology is considered to be due to faulty ossification of the triradiate cartilage. Conditions involving the nervous system are also Illustrated. In an excellent article on the possible relationship of neurofibromatosis, con- genital pseudar thro sis, and fibrous dysplasia, AEGERTER (8l) reviews tissue sections from 15 cases of congenital pseudarthrosis, four of the cases hav- ing lesions of the peripheral nerves which were diagnosed as neurofibro- matosis and ten showing pigmented skin lesions. It is the opinion of the author that the incidence of lesions typical of neurofibromatosis occurring in the presence of pseudarthrosis is too high to be mere coincidence, HEIN and REAVIS (82), on the same subject, give a general discussion. MATUSEWICZ (83) describes a case of Recklinghausen's disease (neuro- fibromatosis) in which there was extensive invasion of central nervous sys- tem improved by the use of roentgen therapy. On the other Recklinghausen's disease, hvoeroarathyroidism, there are four articles. The AMERICAN PRACTITIONER (8*0 publishes a discussion of "polyosotlc fibrous dysplasia" which is felt should be included hero. KRATJSS (85) discusses the diagnosis and treatment in general of "generalized fi- brous dystrophy"; SINIGAGLIA (86), a case of "osteodystrophia fibrosa cys- tica";,and COURTY and LEWAITRE (87), an end result of a case of "Reckling- hausen's bone disease" treated by removal of an adenoma of the parathyroids. STRICKER and LUX (88) report the four year result of a case of gener- alized scleroderma with arthropathy treated by removal of two parathyroids. TAYIX)R (89) reports a rare case of atrophy of the mandible in a 20 year old white male with overlying scleroderma. History suggest a traumatic etiology. The hone change is believed to he pressure atrophy secondary to the contraction of the skin over the angle of the jaw. Various authors present their findings in cases of neoplastic hone diseases. The reticulo-endothelioses of hone are discussed hy BOLGERT (90), with accounts of the clinical and laboratory findings of Letterer-Siwe dis- aase, Perther-Jungling disease, xanthomatosis of hone, eosinophilic granu- loma of hone, and Gaucher’s disease. The possible etiologies are mentioned. A case of xanthomatosis, associated with vertebra plana with multiple deposits in hone and the appearances of vertebra plana of the ninth dorsal vertebra, is described hy DAVIES (91). The initial hone lesions are thought possibly to have been tuberculous in nature or due to the separate existence of both tuberculosis and osteochondritis vertebralis (Calve, 1928). The steps taken to reach a diagnosis are recorded; the Importance of general radiographic examination of the skeleton, in cases showing bone lesions of obscure etiology, is stressed. Attention is called to the value of lateral tomography in vertebral lesions occurring in childhood. References are made to cases reported in the literature in which vertebra plana has occurred in association with the lipoid dystrophies. A case of Hand-Schuller-Christian disease in infancy is discussed by FALK and PRETL (92) in the light of published cases from the world litera- ture. The symptom complex varies quite considerably at this age from that found in the older child or adult. The first signs of the illness rarely appear before the baby is four months old and then, frequently, consist of some typical skin affection like chronic eczema, purpura, or scborrhoic dermatitis. In many instances, these skin changes constitute a preliminary to some inflammatory conditions, e.g. otitis media, etc. Besides these skin manifestations, one nearly always encounters a swelling of the lymph glands, usually generalized and accompanied by enlargement of the liver and spleen. On the well known tetralogy of symptoms, which is scarcely ever seen in its completeness even in older children, evidence of bony changes alone may be present in the baby later in the course of the illness and, rarely, exophthalmos. The blood cholesterol level is hardly ever raised. The children usually succumb to the disease in a few weeks or months, the immediate cause of death being the profound changes in the lung. On clin- ical and morphological grounds, great similarity exists between infectious reticulo-endotheliosis (Letterer-Siwe disease) and Hand-Schuller-Christian*s disease. In the authors* opinion, pathogenesis and etiology of both con- ditions belong to one of the allergic reactions (infection allergy). As- suming this allergic hypothesis, it becomes easy to understand why many in- vestigators in recent times have voiced the opinion that the Letterer-Siwe disease is the forerunner or acute form of Hand-Schuller-Christian*a dis- ease, terminating fatally in the young baby or infant. The characteristic disorder of lipide metabolism of this condition might also be attributed to an allergic response. His findings in a case of the Sturge-Weter syndrome (meningeal heman- gioma) in a girl of 13 relieved hy radiotherapy are outlined ty STRA1TG (93)* Outstanding signs of the syndrome are (a) a portwine nevus on one side of the face, (h) calcifications in the occipital region of the train on the same side, and (c) neurological manifestations due to intracranial lesion* Jacksonian epileptic attacks are commonly seen rather than generalized sei- zures, and paralysis sometimes occurs. BOUCHER and LAPRADB (9*0 report a case of decalcifying myeloma. This is known also as Kahler's disease, Fuffert's disease, Bence-Jones alhumino- suria, and multiple myeloma. BIBLIOGRAPHY 1. Nardell, S, G,: Ollier’s disease, dyschondroplasia, Brit. M. J,, 2: 555-7. Sept 2. 1950 2. Rokyta, M.: Ollier's disease, Gas. lek, cesk., 89: 713-6. June 23. 1950 3. Kierulf, E,: Dyschondroplasia; report of a case, Acta radiol., Stockh., 32: 169-72, Sept 30, 1949 4. Fairbank, E. A. T.: Achondroplasia; synonyms, chondrodystrophia foe- talis, micromelia, J. Bone Surg., 31 B: 600-7, Nov 1949 5. Garth, E. 0,: Follicular atrophoderma and pseudopelade associated with chondrodystrophia calcificans congenita, J. Invest. Derma., 13: 233-47, Nov 1949 6. Marchin, P. de, Collard, A., and Eeusghera, C.: A case of dwarfism with total ovarian insufficiency and hypersecretion of gonadotropic hormone. (Turner's syndrome), Acta din. helg., 5: 201-8, Mar-Apr 1950 7. Greene, R.: Dwarfism, sexual infantilism, diabetes mellitus and anem- ia, Proc. R. Soc. 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V,: Basilar invagination in Paget's disease, Lancet, Lond., 1: 809-11, Apr 29, 1950 40. Schneeberg, N. G.: Observations on the glucose tolerance test in Paget's disease. Am. J. M. Sc., 219: 664-73, June 1950 41. Koch, W. E,, Jr.: Bone changes associated with hyperparathyroidism, Paget's disease and osteofibroma, J. Oral Surg., 8: 16-24, Jan 1950 42. Seze, S, de, and Ordoneau, P,: Paget's disease with pelvic decalcifi- cation of unusual density, Pev. rhumat., 17: 251-3, May 1950 43. McPherson, A, G.: Simple depressed fracture of the skull associated with Paget's disease, Brit. J, Surg., 37: 483, Apr 1950 44. Godlewski, M., and Palun, J.: Maladie de Paget localises; radius cur- ▼ixs et voute cranienne pagettlques, Rev, rhumat,. Par., 17: 79, Feb 1950 45. Lievre, J. A,1 Familial Paget's disease, Rev, rhumat., 17: 254, May 1950 46. Murphy, W.: Osteitis deformans in a brother and sister, Med, J, Aus- tralia, 1: 507, Apr 15, 1950 47. Estridge, M. N.: Paget's disease and intracranial tumor; association with an astrocytoma of right temporal lobe with osteitis deformans, Bull. Los Angeles Heur. Soc., 3-5s 87-92, June 1950 48. Flesch-Thcbesius, M.: Paget's osteitis deformans following sarcoma of the maxilla, Arch. Klin. Chir. (lengenbeck*s), 264: 593-4, Apr 11, 1950 49. Leriche, R.; Syndrome of painful diaphyseal eburnation following bone contusion, Presse med,, 58: 363-4, Apr 5, 1950 50. Aspin, J.: Anomalous ossification of ribs as a cause of pseudarthro- sis, Brit. J. Radiol., 23: 15-7, Jan 1950 51. Coste, F., Galmiche, P., and Brion, S,: A curious case of myositis ossificans 'blocking the hips; reflexions on ectopic ossifications. Rev. rhmnat., 17: 180-8, Apr 1950 52. Freeman, I.s Myositis ossificans progressiva, Brit. J. Radiol., 23: 573* Sept 1950 53* Bariety, M,, and Coury, G.; Hypertrophic pulmonary osteoarthropathy and dysacromelia of thoracic origin; evoluation and anatomico-clini- cal aspects; 25 cases, Sem. hop., Par., 26: 1681-1708, May 14, 1950 54. Copeland, M. M.; Bone diseases with osteoporotic or malacic changes, South. Surgeon, 16: 677-703, July 1950 55* Sherman, M, S,: Osteomalacia, J. Bone Surg., 32 A: 193-206, Jan 1950 56. Leroux, R., and Kernels, J. P.: Atrophic osteopathies; osteoporosis; osteomalacia, Presse med., 57: 1048-C, Nov 9» 1949 57* Hansen, K.: Presentation of an unusually advanced case of osteomala- cia, Nervenarzt, 21: 269-71* June 20, 1950 58. Bertrand, L., and Salvaing, J.: Hanot disease and spinal osteomalacia. Rev. foie, 9: 87-93* Mar-A.pr 1950 59* Howard, R. P.: Medical aspects of hone disease with particular refer- ence to osteoporosis, Canad. M. Ass. J,, 63: 258-64, Sept 1950 60. Kynaston, R. U. F,: On osteoporosis of the spine with spontaneous fracture, Guy*s Eosp. Gaz., Lend., 64: 241-2, June 17* 1950 61. Ravault, P., Vignon, G., and Praisse, H.: Diffuse decalcifying os- teosis and eunuchism, Rev. rhumat., 17: 247-8, May 1950 62. Arden, G. P.; Osteopoikilosis affecting right foot and other hones, Proc. R. Soc. M., Lond., 43: 303-4, Apr 1950 63. Pease, C. N.: Avascular necrosis of hone in children, Med, Clin. N, America, 34: 165-86, Jan 1950 64. Axhausen, G.: Epiphyseal necrosis and slight hone infarcts. Arch. Klin, Chir. (Langenheck1 s), 264: 506-1.8, Apr 11, 1950 65. Pike, M. M.: Legg-Perthes disease; a method of conservative treat- ment, J. Bone Surg., 32 A: 663-70, July 1950 66. Vaeye, J.: Postraumatic ischemic necrosis of the femoral head, Acta ortho, helg,, 16: 85-97* Mar 1950 67• Macdougall, J. T., Glhson, A., and Williams, T, H.; Irradiation ne- crosis of the head of the femur. Arch. Surg., 6l; 325-45* Aug 1950 68. Compere, C. I.; Correction of deformity and prevention of aseptic necrosis in late cases of slipped femoral epiphysis, J. Bone Surg., 32 A: 351-62, Apr 1950 " 69* Siffert, R. S., and Arkin, A* M,: Post-traumatic aseptic necrosis of the distal tihial epiphysis; report of a case, J. Bone Surg., 32 A: 691-4, July 1950 70, Thelander, H. E.1 Epiphyseal destruction hy frostbite, J. Pediat., S. Louis, 36; 105, Jan 1950 71* G-hormley, R. K,, Golden, P. B., end Anderson, M. E.: Traumatic pre- mature closure of the subcapital femoral epiphyseal cartilage; report of case, Proc. Mayo Clin., 24; 581-6, Nov 23» 1949 72. Shimonek, S. W,; Slipping of the capital femoral epiphysis, Minnesota M., 32; 1110-1113, Nov 1949 73* Walch, A,; Treatment of epiphysiolysis of the femoral neck, Acta ortho, belg., 16: 103-10, Kar 1950 74. Pujo, D, M.: Coxa vara, Dia med., B. Air., 21: 2291* Sept 29» 1949 75* Verbrugge, J.: Note on coxa vara in adolescents, A.cta orthop. helg., 16; 398-401, July 1950 76. Ihlenfeldt, G.: Epiphyseal coxa vara and endocrine disorder, Aertzl. Wschr., 5* 365-9, June 2, 1950 77* Furmaier, A.: Diagnosis and therapy of epiphyseal coxa vara, Med. Klin., 45: 690-5, June 2, 1950 78. Pauwels, P.: Treatment of coxa valga luxans, Zschr. Orthop., 79* 305- 15, 1950 79« Marcozzi, G.: Initial radiographic signs of coxitis in childhood, Ann. radiol. diagn., 22: 3-26, 1950 80. F.odgklnson, P..: Arthrokatadysis of the hip joint; report of a case, Med. J, Australia, 1: 405-6, Mar 26, 1950 81. Aegerter, E, E,; The possible relationship of neurofibromatosis, con- genital pseudarthrosis and fibrous dysplasia, J. Bone Surg., 32 A: 618-26, July 1950 82. Hein, G. E., and Reavis, J. C.; Von Recklinghausen*s disease; its relationship to other types of neuroectodermal dysplasia. Am. Practi- tioner, 1: 29-35» Jan 1950 83* Matusewicz, J.: Case of Recklinghausen’s disease with extensive in- vasion of the central nervous system cured with x-rays, Polski tygod, lek., 5: 502-3, Mar 27, 1950 84, Polyostotic fibrous dysplasia. Am. Practitioner, 1: 859-61, Aug 1950 85. Krauss, F.: Diagnosis and therapy of Recklinghausen’s disease, gen- eralised fibrous osteodystrophy, Deut. med. Wschr., 75* 741-2, June 2, 1950 86. Sinigaglia, D.: Recklinghausen’s osteodystrophia fibrosa cystical, Arch, ortop., 63: 193» Apr-Jun 1950 8?* Courty, L., and Lemaitre, G,: Resultats eloignes de lahlation d'un adenome parathyroidien dans un cas de maladie osseuse de Recklinghau- sen, Presse med,, 57: 1212-4, Dec 25, 1949 88. Strieker, P., and Lux, H,: Generalized scleroderma with arthropathy; removal of 2 parathyroids; results after years, Med, Acad, chir.. Par., 76: 485-6, May 3-10, 1950 89* Taylor, D. V.: A case of atrophy of the mandible associated with scleroderma, Brit. Dent. J., 87: 24-6, Nov 4, 1949 90. Bolgert, M,: Otseous reticulosis# Sem. hop., Par., 26: 2773-60, Aug 2, 1950 91. Davies, P. M.: Xanthomatosis associated with vertebra plana, Brit. J. Radiol., 22; 725-8, Dec 19^9 92. Falk, W., snd Pretl, K,: Hand-Schuller-Christian disease in infancy, Helvet. paediat. acta, 5: 229-45. June 1950 93* Strang, G.: The Sturge-Veber syndrome; report of a case showing im- provement after radiotherapy, Edinburgh, M. J,, 56: 409-14’, Sept, 194-9 94-. Boucher, R., and Laprade, C.: Case of decalcifying myeloma or Fabler’s disease. Union med. Canada, 79: 529-33, Way 1950 CHAPTER III TUBERCULOSIS By Clarence R. Brown, Lt* Col*, MC (Deceased) And John D* Ashby, Major, MC Percy Jones General Hospital I. General Considerations A* Clinical Aspects B. Pathogenetic C. Laboratory D* Age and Race E* Forms and Types II* Regional Considerations A* Head and Trunk B* Spine C. Upper Extremity D. Lower Extremity III. Therapeutic Considerations A. Streptomycin B. Streptomycin Experimental C* Para Amino Salicylic Acid D. Other Inhibitory Agents E* Surgical Treatment General Considerations SCHALLE (1) in a good general article emphasizes the necessity for early orthopedic diagnosis in bone and joint tuberculosis* Treatment is outlined in detail including mention of PETHEOSTHOR (the Thorium preparation)* This is sound, brief, but complete and conserva- tive presentation of what a young general practitioner should know about bone and joint tuberculosis* SZTABA (2) reports clinical findings and statistics on a series of 132 children 1 to 7 years of age with osteo articular tuberculosis* LOPEZ-VALLEJO (3) refutes the old theory of Marfan that recovery from glandular tuberculosis confers immunity# He cites cases where pulmonary lesions developed 5-20 years after glandular lesions have healed, and discusses allergy and its coexistence with immunity# He quotes statistics of Kirschener on Prussia showing high mortality in the first year of life, decreasing the tenth year, then increasing with age. He recounts his experience with animal and- human innoculation with BCG and concludes that in small children BCG confers immunity for two or three months and allergy for three to five years. The allergic state, he believes causes a virulent infection to remain localized. OEHLECKER (4) reviews Kochfs work on tuberculosis and discusses laboratory differentiation between human and bovine types, enumerating many causes of false positive findings due to faulty technique. Bovine tuberculosis, he reports, occurs in 4i° of adult cases and 2/£ of children. Bone tuberculosis is frequently more atypical and proliferative by x-ray. SEGHINI(5) reports studies on protein changes in serum in 19 cases of bone tuberculosis. DIAZ-BORBEU (6) recounts sedimentation rate studies in bone tuberculosis and its relation- ship to generalization and localization of the infection, concluding that its prognostic and diagnostic value is questionable. EBHARBT (?) presents 5 cases of "benign" bone tuberculosis in aged persons and concludes that even with inadequate treatment, these patients often are able to recover and even heal. SITTERLSY (8) pleads for more facilities for control of increasing tuberculosis morbidity among the aged. ROLLIER l2l offers an illustrated article on the fresh air and sunshine treatment for children and young adults. SANGIOVANI et al (10) regard cephalalgia as a toxic reaction to tuberculosis of pleura and lungs, quite different from purulent meningitis and simple meningismus. Lumbar puncture performed diagnostically is an excellent therapeutic measure for cephalalgia. Regional Considerations ENGLAND and GOLAN (ll) give reports of two cases of tuberculosis of mandible. FISCHER (12) details autopsy findings in a woman aged 40 who died after having been known to have lymphogranulomatosis for 9 years. She was found to have cancer of the spleen and lung, and new tuberculosis of lung and hilus nodes. HERDNER (13) describes 3 cases of tuberculosis of the sternum localized by tomographic x-ray technique. He explains the method of Zimmer which is taking two slightly oblique posterior anterior exposures on the same film moving the tube longitudinally 1cm between exposures. This blurs the shadows of the ribs and vertebrae and leaves the image of the sternum distinct. MC BURNEY (14) gives a general discussion of the treatment of spine tuberculosis. SORGE (15) stresses the importance of clinical tion in early diagnosis of spine tuberculosis. GARQEAU and BRADY (l6) ask for surgical treatment, if 4 months of conservative treatment fails, and quote comparison in 32 cases. KNIEDSL et al (l?) report a case of a unilateral TB abscess of the thoracic spine and underscore the importance of the postero medial pleural line as a thoracic landmark in x-ray examinatiii| SEREE et al (18) compare the results of early bone graft in Potts disease to classical treatment. In 515 cases there were 46 recurrence of which 40 were after early graft. They conclude that it is better to wait f until the period of activity is ended, before grafting and hope that streptomycin or some other antibiotic will shorten the period of activity. SOUZA-DIAS (19) performed a complete type fusion successfully on a man 58 years old with tuberculosis of sacro-iliac joint. COLANTUONO (20) reports a case of tuberculosis of the scapula in a woman 52 years of age which had been draining for a year and which was cured by excision. X-ray showed bone erosion and bacterial and histological studies reveals tubercle bacilli. The condition is rare — 54 cases have been reported but in 26,000 autopsies at the Institute of Pathologic Anatomy in Rome, only one case was found. KOZLA (21) gives a rather complete discussion of the differential diagnosis of early tuberculosis of the hip and Legg-Perthes’ osteochondritis deformans in juveniles. ROLDAN (22) lauds the symptom of knee cap pain on external ro- tation and abduction of an early tuberculous coxitis. as a diagnostic sign. ARI.IANST 1ill points out that tuberculosis ofr*“the hip soft tissues but not primarily of the joint gives a somewhat different type of picture than ordinary joint tuberculosis. It is usually a simple type of arthritis in young people, mild, completely clearing as focus clears. In patients over 50 years of age it may be more severe but also may clear or may require fusion. Twenty-three cases are reported. JEFFERSON et al (24) find that tuberculosis of greater trochanter is frequently missed by x-ray. Of 105 cases reported in literature, 74% had TB elsewhere in the body. Author had two cases treated by total excision with success. MARTENS (25) studied eleven cases of tuberculosis of the knee and stresses the difficulties of diagnosis, particularly in children. Diagnosis is made clinically and by x-ray. KH00 (26) reports a case of tuberculosis of cuboid and tarsal bones. Therapeutic Considerations In an early report on streptomycin. BOSWORTH et al (27; were especially optimistic in cases with draining sinuses, not so much so with closed lesions. MILLER et al (28) treated two cases of tuberculous tenosyno- vitis on an out patient basis successfully with streptomycin and iramobilizatio: SMITH and YTJ (29) give a detailed report of the results of streptomycin com- bined with surgery in 28 cases of joint tuberculosis. They observed a re- markable influence of the drug on the course of the disease. There were three failures. JONES and HOWARD (30) reduced the death rate in children from to l/o in 101 cases of tuberculosis treated with streptomycin. ARONOVITCH and LEWIN (3l) offer another early paper on the subject. CAWLEY (32) reports a case of intrathecal streptomycin for tuberculous meningitis, with recovery. MARINO-ZUCO (33). HUWYLER (34). GERARD-MARCHANT (35K56). , . ECHSYSRRI (57). AHMTM HE ROJAS (38). ALLEHDE et al (59). and TREMBLAY (40) report on the suooess of streoptomycin and PAS in the therapy of osteo- articular tuberculosis. All agree it is useful. KUTZ et al (4l) report two cases of cystic tuberculosis of bone complicated by tuberculous meningitis which healed with streptomycin and promizole. Experimental work with streptomycin was done by QGINSKY et al (42)« They state that it specifically inhibits an oxidative re- action in susceptible strains of E. Coli. This reaction is apparently the "oxalacetate-pyruvate" condensation and when inhibited prevents a variety of substances from entering the terminal respiration system that resembles the citric acid cycle. BOQEN (43) urges minimal effective doses, i.e., 0.4 gms. per day to lessen danger of development of resistant strains. ADCOCK and Associates (44) studied absorption and excretion and state that streptomycin combines with para-amino-salicylic acid in ratio of 1 g. to 0.8 g. respectively to form paraminosalicylate which when injected IM is only slightly more irritating than an equivalent dose of streptomycin. Plasma and urine levels showed the peak of streptomycin 60-120 minutes after injection, and the PAS peak in 15-30 minutes, but when injected to- gether, levels are lower. TURKISH and MURPHY (45) report the 18th proven case of osteitis tuberculosa multiplex cystica, a l9 month old negro, male, and its recovery with streptomycin and PR0MI20LE. The advantages of using PAS with streptomycin was studied by HOBBY et al (46) in mice with experi- mental tuberculosis. CARR and HINSHAW ( treated 35 patients with dihydro streptomycin and found less neurotoxicity and equal benefit. G00DAGRE and SEYMOUR (48) tried to induce resistance to streptomycin and PAS in 25 strains of Mycobacterium tuberculosis, one strain developed resistance after four months. In a study of PAS blood levels, DYE and WEISER (49) find that 10.8 g or more of PAS at 3 hour intervals maintain a free PAS level of 10 micrograms per milliliter of plasma after two weeks therapy which is a level that inhibits the resistant variants as well as the large mass of the bacterial population. RODRIGUEZ (50)« ZIFRONI (51) believe streptomycin more effective with PAS. TAPIE et al (52) discuss toxic reactions of PAS, nausea and vomiting is rare. One case developed fever and neck pain on two different brands of PAS even without streptomycin. SAMITIER (53) discusses inhibitory agents and argues PAS requisite. KARLSON et al (54) show neomycin less effective than strepto- mycin against experimental tuberculosis in guinea pigs. PAOLETTI (55) experimented on the action of pancreatic extract treated with 24 normal sulphuric acid and concluded that it may kill tubercle bacilli after 24 hours of contact. . BURNS et al (56) treated 24 tuberculous broncho pneumonia patients with PROMIZOLE without favorable response. MILLNER and HURST (5?) treated 30 with NEO-ANTERGAN and PHENERGAN (antihistaminics) for several months with slight improvement. BRANDT (58) used Petheostor a preparation of Thorotrast. Thoriun X has a half life of 5*6 days but Thorotrast has 25i<> Thorium oxide which has a half life of 25 million years. Fuermaier began to use it in 1944 and reported 20 cases in 1949* In no case did it effect menstruation or sperm count but the lay press gave it deplorable publicity. His own series of 11 cases had an average of 50 injections of Peteosthor. It did not seem to shorten the duration of any case of osteoarticular tuberculosis nor is it felt that it had any direct or specific influence on the infection. GRUCA (59) describes an excision of quiescent tuberculosis of the hip, an operation designed to give a stable and freely moveable pseudarthrosis• MeCOMAS (60) gives a review of 88 TB hips, 55 of which were treated surgically. Late results of 25 fusions showed 16 good. He prefers the Ghormley type of fusion with the Wilson graft. GYARMATI (6l) reviews the surgical procedures of Mundblick, Westermann, Multanowazky, Harris, Haas, Schreiner, Adelberg, Johnson, Weldenstrom, Calv4 Key, Gill, Anderson, Orell, Badgley, Hammond, Brittain, and Soviet Union surgeons. LUKANOV (62) describes shoulder arthrodesis using the outer half of the clavicle as a graft, and knee arthrodesis dove- tailing the femur into the tibia. OTERMIN-AGUIRRS (65) reports the case of a 19 year old girl with tuberculosis of the elbow of two years duration who was treated by resection and streptomycin, and who healed in five days three years previously. WEIL (64) compares advantages of open ischiofemoral arthrodesis, quoting Van Gorder and Trumble, and prefers it to the methods of Brittain of driving the graft in blindly and of Voley of osteotomizing the femur. 41 BIBLIOGRAPHY 1. Schalle, H.s Clinical aspects of osteoarticular tuberculosis, Wien* Med* Wschr., 100: 15-16, 277-80, 1950 2. Sztaba, R.: Tuberculosis of bones and joints, Pediat* Polska*, 23: 7-8, 696-706, 1949 3* Lopez Vallejo, J.: Immunity and allergy in tuberculosis, Revista Medicina De Mexico, 30: 602, 176-82, 1950 4* Oehlecker, F.: Clinical and expert considerations on bovine tuberculosis possible in the clinical aspect of osteoarticular tuberculosis, Chirurg., 21: 5, 179-87, 1950 5* Seghini, G*: Protein changes in the course of osteoarticular tuberculosis, Arch* Ortop., 65: 1, 85-9, 1950 6. Diaz Bordeu, E.: Erythrocyte sedimentation and osteoarticular tuberculosis, Rev. 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Polska., 24: 74-82, 1950 22. Roldan, Calleja, R.: The gonalgia symptom in early diagnosis of tuberculous coxitis, Medicamenta, Madr., 8: 179, 208-10, 1950 25. Armanet, B., Contact Hips, Marseille Chir., 2: 207-21, 1950 24* Jefferson, N, C., Palmer, J. M., and Phillips, C. W., Tuberculosis of the Greater Trochanter and its Bursa Treated with Streptomycin and surgery, J. Internal Coll. Surgeons, 13* 561-66, 1950 25. Martens, E., Differential Diagnostic Difficulties of Tuberculosis of the Knee Joint in Children, Schweiz* Zchr. Tuberk., 7* 129-45» 1950 26. Khoo, F. Y.: Osteochondritis of the cuboid associated with Tuberculosis of Adjacent Tarsal Bones, J. Bone and Joint Surgery, 32B: 250-2, 1950 27. Bosworth, D. M., Pietra, A. D., and Farrell, R. F.s Streptomycin in Tuberculous Bone and Joint Lesions with Mixed Infection and Sinuses, J. Bone and Joint Surg., 32A: 103-8, 1950 28. Miller, J. M., Lipin, R. J., and Ginsberg, M.,: J. Am. M. Assoc., 142: 408, 1950 29. Smith, A. D. and Yu, H.I.S.s Streptomycin combined with surgery in the treatment of Bone and Joint Tuberculosis, J. Am. M. Ass., 141* 1-7, 1949 50. Jones, E. M., Howard, W. L., Streptomycin in the Treatment of Tuberculosis in Children, Dis. Chest, 16s 744-60, 1949 51. Aronovitch, M., Lewin, N., Streptomycin in Tuberculosis, Canad. M. Ass. J., 61: 577-83, 1949 52. Cawley, P. F., Streptomycin in Tuberculous Meningitis, Brit. M. J., 1: 249, 1950' 43 35« Marino-Zuco, C.: Gli antibiotic! mella tubercolosi oster-articolare (Antibiotics in osteoarthritic tuberculosis), Arch, ortop., 63: 2, 160, 1950 54* Huwyler, J.: Streptomycin therapy of osterarticular tuberculosis, Schweiz, med. Wschr., 80s 34> 915-6, 1950 35* Gerard-Marchant, P.: La streptomycins dans les tuberculoses osteo- articulaires, Bruxelles med., 29: 45, 5295-5501, 1949 36. Gerard-Marchant, P.: La streptomycins dans les tuberculoses osteo- articulaires, Bruxelles med., 29: 50, 5602, 1949 37* Echeverri, A. J.: Streptomycin in osteoarticular tuberculosis, Medicamenta, 8: 181, 545-6, 1950 38. Aranda de Rojas, M.s Resultados obtenidos con la estreptomicina en el tratamiento de la tuberculosis, Med. & cir. guerra, 11: 11-12, 487-501, 1949 39# Allende, G., Fagalde, A. E.: Streptomycin in tuberculosis of the bone in children, q Rev. As. med. argent, 64: 675-6, 177-81, 1950 40. Tremblay, G. 0.s Streptomycins et tuberculose, Union med. Canada, 78s 11, 1518-21, 1949 41* Kutz, E. R., Macht, S. H., Easton, R. S., Cystic tuberculosis of Bone Complicated by Tuberculous Meningitis, J. Pediat. St. Louis, 56: 550- 66, 1950 ♦ 42. Oginsky, E. L., Smith, P. H., Umbreit, W. ¥., The Action of Streptomycin; the Nature of the Reaction Inhibited, J. Bact., Balt., 58: 747—599 1949 43- Bogen, E., Streptomycin Dosage in the Treatment of Tuberculosis, Dis. Chest. 16s 761-4, 1949 44* Adcock, J. D., Stow, R, M., et al., absorption and excretion of streptomycin para-amino-salicylate, Proc. Soc. Exper. Biol. N.Y., 72: 451-5, 1949 45* Turkish, M., Murphy, J. W., et al., Osteitis Tuberculosa Multiplex Cystica; its Treatment with Streptomycin and Promizole, J. Pediat., St. Louis, 55: 625-9, 1949 46. Hobby, G., Regna, P., Lenert, T., The Chemotherapeutic Action of Streptomycin Paraminosalicylate in Experimental Tuberculosis in Mioe, Am. Rev. Tuberc., 60: 808-10, 1949 47. Carr, D. T., Hinshaw, H. C., et al., The Use of Dileydrostreptomycin in the treatment of Tuberculosis, Dis. Chest, 16: 801-21, 1949 48. Goodacre, C. L., Seymour, D. JS., attempts to Induce Resistance to PAS in M. tuberculosis, J. Pharm., Lond., Is 78Q, 1949 44 49* Bye, W. E., Weiser, 0. L., PAS Blood Levels, Bull. U. S. Army M. Bep., 9: 1055-5, 1949 f 50. Rodriquez, Pastor, J.: El acido para-amino-sallcilico en el tratamiento de la tuberculosis, Bol. As. Med, Puerto Rico, 41: 12, 411-5, 1949 51. Zifroni, A.: Para-amino-salicylic acid in tuberculosis (Hebrew text), Harefuah, Tel Aviv, 58* 1» 20-2, 1950 52. Tapie, J., Laporte, J., Monnier, J., Bovissou, H.: Reactions febriles et manifestations d*intolerance au cours d*un traitement par l*acide para-amino-salicylique, Bull. Soc. med. hop. Paris, 65, 28-29, 1261-4, 1949 55* Samitier, J.; Antibioticos en tuberculosis, Med. & cir. guerra., 11: 11-12, 515-25, 1949 54. Karlson, A. 0., Gainer, J. H., Feldman, V/. H., Neomycin in experimental TBC of guinea pigs, Bis. Chest, 17* 495-502, 1950 55* Paoletti, A.: Effect of extract of the pancreas in combination with sulphuric acid on tubercle bacilli, Acta med. ital. mal. infett., 5* 5, 70-2, 1950 56. Burns, H. A,, Feldman, V/. H., et al., Treatment of Tuberculosis with Promizole, Bis. Chest, 16: 867-9, 1949« 57* Millner, T., Hurst, A., Tuberculosis and Antihistaminico, Bis. Chest. 16: 870-8, 1949 58. Brandt, H.: Treatment of Osteoarthritic tuberculosis with Peteosthor (Troch), Beut. med. Wscher., 75* 17, 622-4, 1950 59* Gruca, A,, A Treatment of quiescent tuberculosis of the hip joint by excision and "dynamic" osteotomy, J. Bone and Joint Surg., 52B: 174-82, 1950 60. McComas, E., Late Results of the Surgical Treatment of tuberculosis of the hip, Med. J. Australia, 1: 457-9, 1950 61. Gyarnati, L.: New surgical methods in treatment of osteoarticular tuberculosis, Magy. sebeszet, 2: 5, 29-56, 1949 62. Lukanov, A.T.: Surgical treatment 01 osteoarticular tuberculosis in Bulgaria, Vest. khir., 70* 5, 50-5, 1950 65. Otermin-Aguirre, J. A.: Reseccion de codo por osteoartritis tuber- culosa, Bol. Soc. argent, cir., 10* 27-28, 856-9, Nov. 25-28, 1949 64. Weil, S.s Bie ischio-femorale extra artikulHre arthrodese, Zschr. Orthop., 79* 2, 589-92, 1950. 45 CHAPTER IV MI SC ELLANEOUS SUBJECTS By Robert P. Legge, Captain, MC, USN U. S. Naval Hospital Mare Island, California I* General progress II. Wound healing A. Delayed suture B. Wound rupture C. Grafts D. Tissue reactions III. Peripheral vascular conditions A. Patho-physiology B. Arteriography C. Collateral circulation D. Thrombosis B. Gangrene IV. Miscellaneous A. Occupational therapy B. Calcium and phosphorus content of the diet There have been 19 articles abstracted for this chapter which are con- sidered to be among the best of the 262 titles selected as aMiscellaneous Subjects•w The majority of them have to do with wound healing and peripher- al vascular conditions. General Progress Significant recent advances are reviewed by 0'BRIER (l) and, In essence, are antibiotics, epiphyseal stapling, bone bank, the vltallium cup, femoral head prostheses, and the Intramedullary nail. Wound Healing Delayed suture In the management of 721 traumatic wounds Is analysed by LOWRY and CURTIS (2), They report that, when suture was accomplished four to six days from the Initial debridement, no undermining, trimming or exci- sion was necessary, and per cent of the wounds In this group ( 19 per cent ware so treated) healed. When the Interval was seven days or longer, undermining and excision of wound edges was necessary, and only 86,7 per cent healing was obtained (68 per cent were so treated). In 12 per cent in which excision en masse was used, there was 91 per cent healing. The authors con- clude that healing occurs In over 90 per cent when suture is accomplished ■between the fourth and seventh days and that the optimum time interval Is at the fourth or fifth day. The cause of wound rupture In 6l cases out of 12,786 celiotomies Is re- viewed hy LAHDRY et al (3!) * Age, sex, season of the year, the particular surgeon, hypoproteinemia, suture material, use of a drain, type of anesthes- ia, and contamination of the wound have little hearing on whether the wound ruptures or not* The striking factor is the high incidence of cough, abdom- inal distention, vomiting, and urinary retention during the postoperative course of wound rupture cases, 95 per cent to he exact* It is the authors* belief that these and other causes of increased intra-abdominal pressure pre- vent the effective repair of the wound, (Ed: Although wound rupture is not a major problem of orthopedic surgery, this article is included because of the evidence of the effect of internal pressure on wound healing,) Various full thickness pedicle grafts and their Indications are dis- cussed by MARTIN and BRAUER (h) in respect to replacement of unstable scar tissue and in preparation for bone or tendon surgery in the lower extremi- ties, Simple closure and split thickness grafts usually suffice over soft tissue defects; however, when the defect is over bone or tendon, pedicle tis- sue usually is required. The double pedicle is useful in linear defects of the upper two-thirds of the leg when the secondary defect does not occur o- ver the tibia, popliteal space, or Achilles tendon, A local flap is useful where the double pedicle is not feasible and usually only about the knee where the circulation is excellent. Cross leg calf grafts are valuable when a graft is necessary from a distant area. A cross open thigh flap to the opposite distal one-third of the leg is highly useful when large amounts of tissue are needed. An open abdominal flap graft can be used in selected cas- es, when mechanically practicable, by migration via the forearm for covering of very large defects. Also in large defects, particularly when bone sub- stance is missing, an abdominal tube graft is applicable since the fat car- ried with it is available to aid in rounding out the bone defect. This graft is migrated to the lower extremity by first attaching it to the wrist, Each case is an individual matter, but, in view of the speed and simplicity of an open flap graft, this method should be employed whenever possible. Successful take of skin grafts are given by LWIS (5) as: an aseptic base, adequate blood supply in the recipient area; correct timing, three to four weeks after burns; a clean, firm, cherry red and not too exuberant, granulating surface; and good general conditions (no anemia). The graft must be held firmly in contact with the recipient area "by the use of sea sponges, mechanic*s waste, or wax stents, which are left in place for four to nine days. In 27 cases of transplantation from one person to another, 100 per cent failure is reported. If Insufficient skin is available, twice the area can be covered by cutting the graft into postage stamp squares, placed one centimeter apart in checker board fashion. Tissue reactions, specifically chlorophyll and wound healing, is the subject of an experimental and clinical study by LAM and BRUSH (6), In their experiments with 102 guinea pigs, the control wounds healed in an aver- age of 10,2 days, while the chlorophyll treated ones took nine days. In the graft site experiments on five patients, all wounds healed in 10 days. In the burn cases, using chlorophyll on one side and vaseline gauze on the oth- er, no favorable effect of chlorophyll was evident. In the ulcer cases. 47 healing time was slightly shorter when chlorophyll was not used. The auth- ors conclude that in no instance was a favorable effect produced by cholor- phyll. The effect of dicumarol on wound healing is the subject of experiments by TAYLOR and ZIPPERMAN (?)• The method of direct observation and histology ic study is used in wounds made in dogs* When the prothrombin levels are kept at 10 per cent or less, there is a definite tendency on the part of the experimental wounds to bleed with the result that hematomata develop* These definitely weaken the wound and delay healing* When the bleeding in the ex- perimental wound is controlled, no detrimental effect of dicumarol on the healing rate is noted* Hadiation injuries of the skin are analyzed by TELOH et al (8) in 215 specimens removed from 121 Individuals with postradiation dermatitis. Chang- es noted in the epithelium after irradiation are atrophy, acanthosis, hyper- keratosis, and, occasionally, parakeratosis. Dysplasia of the epithelial cell is felt to be a stage in the formation of the carcinomatous lesion. Vascular changes in postirradiation dermatitis consists of alteration of the endothelium, degeneration of the media and adventitia, perivascular lympho- cytic infiltration, and occasional thrombosis. The end product is marked endothelial proliferation with decrease of the lumen and fibrosis of the med- ia and adventitia. Stromal changes, which are non-specific, are partly the result of inflammatory response to irradiation and partly due to the vascular change with ischemia. The hair follicles and sebaceous glands are extremely sensitive to radiation injury. The sweat glands are found to be the most re- sistant structure to Irradiation injury, but they undergo various stages of atrophy and are an excellent index of the degree of irradiation injury. In the 121 individuals with Irradiation damage, malignant changes are seen to occur in 28.1 per cent. Malignancy is found usually to be localized by the stromal barrier. The fundamental biologic behavior is, however. Identical with that of any squamous cell carcinoma of the skin. Tantalum mesh is strongly advocated by K00NTZ and KIMBERLY (9) for closing defects in the abdominal wall due to hernia* It is very well toler- ated by the body with fine fibrous tissue laid down about it* If exposed to the peritoneal cavity, it becomes covered by fibrous tissue and peritoneum* The mesh will not migrate and will not interfere with growth when used in young puppies* Infected wounds heal well with the mesh in place* Peripheral Vascular Conditions The -patho-phra iology and treatment of the lover leg stasis syndrome is discussed hy BAXTER (10) in an outline of the physiology of leg vein re- turn circulation in conjunction with an explanation of the rationale of pop- liteal vein division and resection for cases of chronic edema» induration, and ulceration of the leg. The importance of a "peripheral heart" action of the calf muscles is described as a factor in the venous stasis syndrome. Thus, a possible means of overcoming venous stasis is by eliminating the backflow of large, avalvular trunks by resecting same and, thereby, forcing the return flow through collateral venous channels with functional valves. Hence, the efficacy of popliteal vein resection in these cases where the valves have been destroyed by thrombosis or phlebosclerotic processes is shown, and it is stated, and clinically well verified, that after this oper- 48 ation the calf muscle contractions drive the blood through numerous fine- calihered channels into the muscle reins of the thigh, and that no backflow can occur. The arteriography of the lover extremity is reviewed in detail by CAMP- BILL and SMITH (ll).The technique, indications, contraindications, compli- cations, benefits, and advantages are given. Two important contraindications mentioned are deformities which make x-rays difficult and sensitivity to the contrast material. Arteriography is a distinct aid in determining the site of a proposed amputation and in selecting suitable candidates for lumbar sym- pathectomy. A specific indication, in a small number of cases of segmental occlusions in major vessels requiring repair by vein grafts, is also mentioned. Collateral circulation in the presence of experimental arteriovenous fistulae in dogs has been measured by ROBERTSON et al (12). They conclude that the policy of delay in the treatment of an arteriovenous fistula to al- low for the maximal development of collateral circulation is sound and is supported by their experiments. Varicose veins, according to PRATT (13) as seen in his clinic, usually require surgery. Only about 10 to 15 per cent of the patients are proper subjects for injection treatment alone. Surgery consists of (a) resection of each branch of the greater saphenous vein in the groin with resection of a three inch portion of the vein itself and ligation flush with the femoral vein, (b) a wide resection at each incompetent point with ligation of each perforating vein, (c) resection of the lesser saphenous vein at the popli- teal insertion, and (d) stripping of the veins between the groin and each in- competent point. Causes of failure in simple varicose vein therapy are dis- cussed. Venous thrombosis is discussed in articles by PRATT (13) as well as by 0CHSN3SR et al (14, 15)* Thrombophlebitis is defined as an inflammation of the wall of a vein with a secondary clot, firmly attached, infrequently de- tached and then only with suppuration and liquefaction. Symptoms are severe, with pain, fever, and swelling. Phlebothrombosis is defined as the formation of a loosely attached clot which nay be easily detached. The in*©disposing cause is alteration in the blood, favoring coagulation, the result of tissue injury. The precipitating cause is circulatory stasis and is combated by early ambulation, active muscular contraction against resistance, compression bandages to accelerate deep venous flow, and deep breathing to assist venous return to the heart. Anticoagulants are dangerous because of the hemorrha- gic tendency they produce. In addition, constant vigilance for early devel- opment of phlebothrombosis and prompt thrombectomy and ligation, are indi- cated. Phlebothrombosis occurs when the antithrombin level of the blood is proportionately lower than the prothrombin. It is diminished in most post- operative cases and usually returns to normal in four to five days. If the proportion is less than 1:16, phlebothrombosis is possible. Alphatocopher- ol.and calcium are effective. Oangrene as a complication of venous thrombosis is reviewed by HAIMO- VICH (16), and cases are reported. Gangrene usually remains superficial and limited, and a conservative surgical approach to the condition is recommended. A case of ischemic necrosis of the anterior tibial muscle is contri- 49 tilted by TILLOTSON and COVENTRY (I?)- Since sir other similar cases have appeared in the literature* In the case cited, the authors report on- set of pain and swelling of the leg following a four mile hike, patient de- veloping foot-drop fire days later. They describe treatment consisting of transplantation of the peroneus longus into the middle cunieform* Biopsy of the anterior tihial is said to have shown avascular muscle with fibrous tis- sue, inflammation and necrosis, fragmentation, loss of striatlons, and edema. Pathogenesis is considered to be a reflex spasm of the anterior tlblal artery due to retention of lactic acid incident to muscular fatigue, producing an- oxia and eventual necrosis. Recommended treatment consists of early recog- nition, splinting, slight elevation, papaverine, paravertebral block, or ar- teriectomy, all within twelve hours of onset. Miscellaneous What every physician should know about occupational therapy is grouped by LIGHT (18) under five headings as foHows: (a) reraed ial exercise, (b) graduation of exercise, (c) improvement of tonus, (d) influence on the mind, and (e) evaluation. (Ed: This is an interesting and readable article.) The effect of the calcium and phosphorus content of the diet upon the formation and structure of bon© is illustrated by CARTTAR et al (19) in ex- periments with rats. Animals on ”adequate” (0.2 per cent Ca) diets show short metaphyses indicating inadequate calcium storage, great osteoblastic and osteoclastic activity indicating maximum utilization of calcium, osteoid borders on trabeculae indicating poor storage of calcium, and a porus shaft as in very young animals. On "optimum” (0.8 per cent Ca) diets, there is maximum calcium storage, maximum calcium utilization, maximum calcification of trabeculae with no osteoid, and a very dense shaft as in adults. On high calcium diet (2.0 per cent Ca) with no phosphorus increase, there are osteoid trabecular borders, diminished depth of calcification of the epiphyseal car- tilage, retardation of invasion, removal of the epiphyseal cartilage, and a rachitic metaphysis. 50 BIBLIOGRAIKY 1. 0*Brlen# R. M,: Progress in orthopedic surgery, J. Missouri M. Ass*, 4?: 493-5, July 1950 2. Lowry, K, P,, and Curtis, G. M.: Delayed suture in the management of wounds; analysis of 721 traumatic wounds illustrating the influence of time interval in wound repair, Am. J. Surg., 80: 280-?, Sept 1950 3* Landry, B. E,, Nolan, J. 0*L, and Burns, J. P.: Wound rupture. Am. J. Surg., 79: ?8?-92, June 1950 4* Martin, E. C., and Brauer, H* 0*: Soft tissue cover of defects of the lower extremity. Am* J, Surg., 79: 244-51, Feb 1950 5* Lewis, 0. K.; Practical points on skin grafting. Indust. M., 19: 61- 6, Peh 1950 6. Lam, C* R., and Brush, B. B.j Chlorophyll and wound healing; experi- mental and clinical study, Am. J* Surg., 80: 204-10, Aug 1950 7* Taylor, P. W*, and Ziperman, H. H.j Effect of dicumarel on wound heal- ing, Am. J. Surg., 80s 113-6, July 1950 8. Teloh, H. A., Mason, M. L., and Wheelock, M. C.: A histopathologic study of radiation injuries of the skin, Surg. Gyn. Ohst., 90: 355- 40, Mar 1950 9. Zoonts, A. R., and Klmherly, R. C«: Tissue reactions to tantalum mesh and wire, Ann. Surg., 131: 666-86, May 1950 10. Bauer, 0.; Patho-physiology and treatment of the lower leg stasis syndrome, Angiology, Balt., 1: 1-8, Pet 1950 11. Campbell, D, A., and Smith, R. G.: The arteriographic examination of the lower extremity, Angiology, Balt., 1: 100-5, Feh 1950 12. Robertson, R. L., Dennis, B. W,, and Elkin, D. C.: Collateral circu- lation in the presence of experimental arteriovenous fistula; deter- mination by direct measurement of extremity bloodflow. Surgery, 2?: 1-16, Jan 1950 13. Pratt, G. M.: Classification and treatment of the varicose, postthrom- botic, and arterial venous problems. Bull. N. York Acad. M., 26: 306- 28, May 1950 14. Ochsner, A., Kay, J. M., De Camp, P. T., Hutton, S, B., and Balia, G. A.: Newer concepts of blood coagulation, with particular reference to postoperative thrombosis, Ann, Surg., 131: 652-65, May 1950 15* Ochsner, A., DeBakey, M. E., and DeCamp, P. T.: Venous thrombosis, J. Florida M. Ass., 37: 79-82, Aug 1950 51 16* Haimovici, H,: Gangrene of the extremities of Tenons origin; review of the literature with case reports. Circulation, IT, T,, Is 225-*K), Feh 1950 17, Tillotson, J. F,, and Coventry, M. B,s Spontaneous ischemic necrosis of the anterior tihial muscle; report of case, Proc, Mayo Clin,, 25* 223-7, Apr 26, 1950 18, Licht, S,j What every physician should know about occupational ther- apy, J, Am, M, Ass,, 104: **72-*f, Feh 18, 1950 19, Carttar, M, S,, McLean, F, C., and Urist, M, H,s The effect of the calcium and phosphorus content of the diet upon the formation and structure of hone. Am, J, Path., 26: 307-31* Mar 1950 52 CHAPTER V RESEARCH By Knox Dunlap, Colonel, MC and James D, Amos, Major, MC Madigan Army Hospital Tacoma, Washington I, Endocrine system A, Steroids B, Other conditions II, Tissue growth A, Requirements B, Tissue extracts C, Vitamin deficiency D, Miscellaneous III, Vascular system A, Anatomical B, Clinical research C* Serum electrolytes IV, Nervous system A, Temperature regulation B, Anaesthesiology C, Embryology D, Miscellaneous V, Muscular system A, Strength and spasm B, Physiology C, Biochemistry - metabolic D, Biochemistry - physio logical E, Muscle relaxants VI, Skeletal system A, Osteogenesis B, Anatomy C, Biochemistry VII* Miscellaneous There were 157 articles submitted for abstracting in this chapter, hut due to various reasons, only 69 were received. These abstracts were omitted mainly because they were worthless* Endocrine System Foot articles follow on the subject of steroids. Hie influence of hy- aluronidase and steroids on permeability of synovial membrane is reported by SEIPTER et al (1), who found the permeability of the synovial membrane as measured by speed of absorption and excretion into the urine of phenol- sulfonphthaleln (PSP) instilled into the joint to be surprisingly constant in a group of 16 rabbits. Hyaluronidase markedly increased permeability of the synovial membrane. The effect was maximal and was not augmented by des- oxycorticosterone. Adrenal cortical extract decreased permeability of the synovial membrane and antagonized the effect of hyaluronidase. Desoxycortl- costerone increased maximally the permeability of synovial membrane to the same extent as hyaluronidase and could not be augmented by hyaluronidase. The physiological effects of cortisone and ACTS in man are reported by SPRAGUE et al (2). Clinical and metabolic studies of 33 patients who re- ceived cortisone or ACTH were studied. The greatest number of these cases were rheumatoid arthritis. The studies were concerned chiefly with the pro- longed administration of the hormone. The capacity of cortisone when admin- istered in sufficiently high dosage for a protracted period to induce most of the clinical and metabolic features of Cushing1s syndrome was demonstrat- ed. The features so induced in varying combinations included rounding of the facial contour, hirsutism, acne, keratosis pilaris, muscular weakness, edema, amenorrhea, cutaneous striae, mental depression, impairment of carbo- hydrate tolerance, negative nitrogen balance. Increased excretion of corti- costeroids in the urine, hypochromia, hypopotassemia, alkalosis, and negative potassium balance (in some cases). ACTS caused disappearance of eosinophils. HOWES et al (3) state that cortisone (compound E) retards the forma- tion of granulations. It also slows, but does not stop, eplthellzatlon. These observations have been made on man and on two different laboratory an- imals. The PROCEEDINGS OP THE FIRST CLINICAL ACTH CONFERENCE (4) is reviewed. The drug is said to have an effect on eosinophil count, hypertension, leu- kemia, lupus erythematosls, periarteritis, and all collagen disorders. Ben- efit from its use is found in glandular disturbances, several personality disorders, mental depression, delirium tremens, and possibly other conditions which are being investigated. The importance of rapid dissemination of good well—controlled scientific data as is done in this book and the various re- actions to the medical progress brought about are discussed. It is felt that diabetes is a minor complication, if any, to the prolonged administra- tion of the drug. Two articles are abstracted on other conditions of the endocrine sys- tem. The influence of sex hormones on tolerance to aminopterin is discussed by VEINTRAUB et al (5). Folic acid synthesis by Intestinal flora decreased the toxicity of aminopterin in mice on an otherwise folic acid deficient di- et. The addition of 10 per cent succlnylsulfathiazole to the diet gave more consistent results though aminopterin tolerance was lowered. The results of adrenal function tests in chronic polyarthritis are given by COSTS et al (6). Thorn's haematological and metabolic adrenaline tests yielded very much the same result* in polyarthritic, spondylarthritlc. and control subjects. The significance of Thorn*s test is doubted. It is considered necessary to determine whether adrenaline influences the number of eosinophils in the blood and the excretion of urates only via the adren- ocortical route, which is probable but has not been proved. On the other hand, the fact that eosinophilla could be produced by means of various stim- ulants (injection of gold salt, normal serum, etc.) indicates that the hae- matologlcal test is very sensitive. This does not decrease its value but it affirms Selye's theory of the extreme commonness of adrenocortical alarm reactions and their production by numerous and highly variable factors. Tissue Growth Requirements for tissue growth is the subject of three articles, in one of which STEARNS (7), considering human requirements, points out that calcium, phosphorus, and magnesium are usually considered together from a nutritional point of view, because all three occur in bone, and with carbon- ate, make up the major part of bone mineral. Ample evidence exists that de- ficiency of Intake or utilization of these minerals results in slowing of growth and lengthening of the growth period; it is possible that such defi- ciencies in adult life may hasten senescence. Milk has considerable calcium and when it is drunk increases growth. Nearly all foods contain ample phos- phorus and magnesium. EDEN and SELLERS (8) recount their findings regarding the absorption of vitamin A. Pour hours after the administration (orally) of vitamin A esters, almost complete hydrolysis had occurred in the intestinal lumen of some bovines, whereas in others hydrolysis was only partial. Examinations performed on the intestinal mucosa at the same time showed that about 75 per cent of the absorbed vitamin A was in the ester form, and the same was true in animals dosed with vitamin A alcohol. The results indicate that the Intestinal wall is capable of esterifying free vitamin A alcohol, but so far no evidence could be obtained that the esterified vitamin A is absorbed in its unaltered form. MARGOLIASE (9) reports on tissue extracts and he found that when sev- eral acetone fractions of adult chicken heart extract were prepared and their growth-promoting power tested on 3rd passage cult tire of fibroblasts derived from eight day old chicken embryo hearts, the acetone precipitate possessed less that 25 per cent of the growth-promoting activity of the or- iginal extract. Protein denaturation occurring during precipitation was not the cause of loss of activity. The acetone-soluable fraction of the heart extract contained no growth promoting activity. Combination of the two fractions resulted in a restoration of the full growth-promoting activity of the original heart extract. It is suggested that these results support previous reports that "the in-vitro cell growth-promoting effect of adult tissue extracts depends on at least two factors or two series of factors acting together to produce the total effect.” MEITES (10) reports that diethylstilbesterol and the natural estrogens depressed the growth rates in 70 normal rats. It was shown that this was due mainly to its ability to depress appetite in the case of the diethylstil- hesterol while the natural estrogens had less effect on the growth rate and did not decrease food consumption. Larger doses of the diethylstilhesterol gave greater growth inhibitory effects* 55 GERSH and CATCHPOLE (11) report an extensive study of the organisation of ground substance and basement membrane and its significance in tissue in- jury and disease* Ground substance of connective tissue and the homogenous component of the basement membrane are closely related substances* They contain glycoproteins which form a fluid to gel-like medium* They infiltrate and enclose a network of oriented fibrils or fibers and it is suggested that ground substance including basement membrane is polymerised and presumably structurally organized on a submicroscopic level and that this polymeriza- tion varies depending on age, activity, and degree of pathologic change. Chemical and physiological properties are defined and morphological evidence is given of changes occurring in permeability of blood vessels, growth of neoplasms, spread of metastases, and in certain endocrine glands, cartilage and bone* BALCEER and LICESTEIS (12) report a study of effect of homobiotin and norbiotin on yeast. They present data to show that, although homobiotin and norbiotin exhibit antibiotin activity against certain strains of yeast, for others these compounds may replace biotin for growth* Vitamin deficiency is the subject of two articles. In one of these articles, MURRAY and KODICEK (13) found that when guinea-pigs were subjected to total deprivation of vitamin C they showed classic changes and since the proximal ends of the tibial diaphyses were destroyed by repeated microfrac- tures, the epiphyses came to overlap, the narrow zone of the tibial shaft now in contact with it, both laterally and medially* The damage to the epi- physes was usually greater medially than laterally, making the animal bow- legged, When the animals, in which these changes had occurred during a per- iod of total deficiency, were again given the vitamin, reparative changes restored the tibia to a form approaching the normal. These changes were; (a) the formation of a subperiosteal thickening in the widened periosteal cambium which filled the angle between the overhanging epiphyses above, the fibrous layer of the periosteum and the old diaphyseal wall, (b) the forma- tion around the proximal end of the diaphyses of cartilage derived from the periosteum, and its later replacement by endochondral bon© which was added to (c) a trabecular bone formed endochondrally at the growth cartilage* All these changes occurred in some cases, but not in all and there was great var- iation in detail* Joint lesions in acute and chronic scurvy are reported in growing and young adult guinea pigs by PIRARI et al (Ik), The incidence and severity of haemorrhagic arthropathy declined in chronic scurvy. Whereas intraartl- cular lesions may improve spontaneously, periarticular changes are less prone to regress even after therapy. Periarticular fibrosis seems to be responsible for the persistent functional impairment in scurvy. The scorbu- tic lesions are different from those seen in rheumatoid arthritis and rheu- matic fever* Under miscellaneous CRAWFORD (15) presents the results of an experi- mental study of tendon growth in the rabbit. Small India ink marks were made at intervals along the length of tendons in the limbs of young rabbits and the distance between the marks was measured during the operation. The rabbits were killed two to three months later, and the amount of longitudin- al growth that had occurred was determined by remeasuring the distance be- tween the marks. The experiments showed that the whole of the tendon grows 56 interstltially in length, hut that maximal growth occurs near the muscle tendons Junction. The marking did not seem to interfer with the tendons. Vascular System One article hy FERGUSON (16) on anatomical considerations makes some observations on the circulation in foetal and infant spines. A step has been taken toward the classification of the arterial circulation of the spine. Zh foetal and infant spines were studied. The pedicles, transverse process, articular facets, and laminae have a good arterial blood supply the anastomosing branches of the posterior rami from the paired seg- mental arteries of the thoracic and abdominal aortas. Two articles are reviewed on clinical research. Investigating for the eosinophil response to surgical trauma, COPPINGER and GOLDNER (17) find that individuals with normal adrenal cortical function show a fall in the number of circulating eosinophils following surgical trauma. The degree of fall is directly related to the length and severity of the trauma and the time interval required for recovery is longer after the more serious procedures. Elderly individuals show a more marked depression and delayed recovery than do young individuals. Preoperative and postoperative complications produce and maintain a fall in the circulating eosinophil level. JACOBS and RAFBL (18) report a comparative study on a microscopic ba- sis of absorbable hemastatlc agents - fibrin foam, gelatin sponge (gelfoam), and oxidized cellulose. From this study, using the sockets of extracted mandibular teeth of a dog, an attempt has been made to determine the degree of absorbability of the materials, their effect on bone and soft tissue healing and the inflammatory responses to them.. It appears that fibrin foam disappears first and that oxidized cellulose remains longest. The method of disappearance of the substances is not known but phagocytosis by giant cells, leucocytes, and the presence of lytic substances appear to play a role. Ep- ithellzatlon is not significantly altered by fibrin foam while cellulose and gelatin sponge retard it. Three articles are included on the subject of serum electrolytes. POP- OVICI et al (19) report on the experimental control of serum calcium levels in vivo. The ability of ethylenedlamine tetra-acetlc acid to form undisso- ciated calcium complexes at physiological Fh was utilized as a tool to regu- late available serum calcium levels in vivo. Further evidence has been pre- sented for the regulatory action of magnesium ion on serum calcium levels. In an article entitled"Electrolyte Problems in the Surgical Patient, with Particular Reference to Serum Calcium, Magnesium, and Potassium Levels,' MARTIN et al (20) report that serial determinations of serum calcium, mag- nesium, and potassium levels were performed in six patients with nasogastric suction who were receiving only intravenous fluids* A drop in the serum calcium magnesium, and potassium occurred in each patient* One patient de- veloped tetany* The magnesium was lost in the urine. The loss of potassium was found in alkalosis, prolonged nasogastric suction, prolonged use of par- aventral fluids without potassium, and in fistulas and diarrhea. Variations in the protein-bound Ca in the blood (as determined by an unpublished personal method) are of interest in the diagnosis of certain 57 diseases, state ED CHE ELD and HOCHFELD-OLLIVIERO (21)* Attention Is drawn to the idea of diffusible Ca, represented by the difference between total and protein-bound Ca* The following were studied in turn; (a) effects of synthetic oestrogens and testosterone implantations on the blood Ca, (b) hypercalcaemia induced by injection of Ca gluconate, and (c) hypocalcaemla induced by intravenous injection of citrates* The variations of the diffus- ible and protein-bound Ca fractions were studied in all of these cases* Nervous System Under temperature regulation* HILL and RUTLEDGE (22) report effects of large molecular and particulate substances on body-temperature of rats* India ink, suspensions of blood charcoal, carmine, and trypan blue were in- jected subcutaneously and intraperitoneally. Carmine was also Injected in- tramuscularly. After subcutaneous and intramuscular injection a rise in body temperature was observed. SOUNENSCHEIft and IVY (23) report a failure of oral antipyretic drugs to alter normal human pain thresholds. It is suggested that either our con- cepts of antipyretics as analgesics is in error or our methods for determin- ing sensitivity to pain are inadequate. Subjects tested by electrical stim- ulation of the tooth showed no greater increase in thresholds when given acetanilide, aminopyrine, phenacetin or aspirin than when given lactose. Similar results were given by a modified Hardy-Wolff-G-oodell radiant heat test. Untreated controls showed no statistically significant changes. The decrease in pain noted with placebo or drugs is ascribed to psychic factors or to the action of these substances upon the pathological processes which cause pain. Anestheslology is the subject of two articles, one of which is report- ed by POULSEfT and SECHER (24) who state that stimuli supramaximal for dir- ect muscle nerve preparations in the unanesthetized animal Invoked little if any response during ether anesthesia* The Injection of 0.00? - 0,18 milli- grams /kilogram "neostigmine” (Prostigmine) intravenously inhibited the ef- fect of ether on muscle contraction. It is suggested that ether affects the function of the motor end-plates. BROWN (25) in reviewing the advances in anesthesiology remarks that the development of modern technics and less toxic analgesic drugs makes it possible for the anesthesiologist, after proper evaluation of the patient by clinical and laboratory methods, to administer any anesthetic drug or combination of drugs by a technique and in a concentration that will least disturb the normal human economy under any surgical procedure. This also involves chemotherapy and proper replacement therapy with fluids, electro- lytes, blood, and blood fractions. There is only one article on embryology and it is written by VATTER- SON and SPIR03TP (26) who discuss the factors responsible for the development of the "glycogen body4* in the roof plate of the chick spinal cord at the level of spinal nerves 26-29 by unilateral and bilateral leg-bud extirpa- tion. The lateral motor columns are extremely hypoplastic after unilateral leg-bud extirpation and may be completely lacking on both sides in cases of bilateral leg-bud extirpation. There is a definite reduction in length of the glycogen body following both unilateral and bilateral leg-bud extirpa- 58 tion, The glycogen body is asymmetrical following unequal reduction of the periphery on both sides. There is little, if any, reduction in volume of the glycogen body prior to 15 days of incubation, but there is a suggestion that after the 15th day its volume will be smaller in operated than in norm- al embryos. This is perhaps correlated with a change in the growth charact- eristics of glycogen body at about the 15th day. Since reduction of the periphery exerts so little effect upon the development of the glycogen body, the causal factors which control this development, if they reside outside the neural tube, must lie close to the latter. The size of the glycogen body level of the cord appears to control precisely the size of the adjacent vertebral canal. This control cannot be due to mechanical pressure alone, since the size of the vertebral canal greatly exceeds that of the contained spinal cord in the lumbosacral region. The shape of the vertebral canal is determined to a considerable extent by the shape of the spinal cord at the glycogen body level, again by factors acting over some distance. Under the heading of miscellaneous has been placed an article by BURG- SET et al (2?) who state the effect of botulinum toxin on isolated rat phren- ic nerve diaphragm preparation is that of an irreversible paralysis. The toxin presumably attacks the motor nerves after it has lost its medullary sheath entering the end plate. Muscular System Strength and spasm of the muscular system is the subject of four arti- cles, the first of which by HAKIM and GERSTUN (28) reports the studies of objective recording of muscle strength. Data were collected on 20 young wo- men and four men. Repeated observations over a period of weeks indicated there were only slight variations in muscle power for any one individual. Tests were performed in the recumbent position and footboards were used to prevent slipping. Muscle power in forearm flexion averaged 28,05 pounds greater with use of the footboard. Muscle power of the forearm flexors was greatest when the angle at the elbow was between 80 and 90 degrees, and de- clared when the angle was increased or decreased beyond this range. KUGELBEEG and PETERSEN (29) describe and discuss the insertion poten- tials found in electromyography of normal, denervated, and dystrophic muscles. HARELL et al (30) discuss the problem of spasm in skeletal muscle, which is a reversible state of sustained involuntary contraction accompanied with muscular shortening and associated with electrical potential changes. Groups of patients with various types of low back pain, fractures, and po- liomyelitis have been examined carefully for the existence of muscular spasm using electromyographic technics. Only -in an inconsequentially small number could such spasm be detected. It is believed this diagnosis is erroneous many times, A strong plea is made for thoughtful use of the term spasm dif- ferentiating it carefully from spasticity, tonus, contracture, cramp, and rigidity. CLAEKE et al (31) report a study of the amount of muscle strength that may be applied for the same movement of a joint when the body is in different positions and the amount of muscle power applied throughout the range of movements of each joint. Graphs made of the muscle power out the range of movements of joints reveal that extension of the hit) and of 59 the elbow prolace a descending curve* Ascending curves were produced by ex- tension of the knee, forward flexion of the shoulder, and abduction of the shoulder* The first two motions produced steep curves and the last two pro- duced curves with plateaus* Flexion of the elbow, adduction of the shoulder, extension of the shoulder, and extension of the knee produced an ascending descending curve* Physiology of the muscular system is the subject of six articles. GORDON and PHILLIPS (32) demonstrate the separation of the slowly contract- ing deep component and rapidly contracting superficial components of muscles. They have compared isometric twitches of the slow part of the tibialis anter- ior in cate with those recorded from the whole muscle in the same prepara- tion. The slow part gives simple twitches with a crest time of milli- seconds. Twitches from the whole muscle show a sharp initial crest at 18-23 milliseconds, with a hump during relaxation which corresponds to the crest tine of the slow component. The resting tension of isolated muscles is measured by HILL and PARK- INSON (33) with a strain gauge with a sensitivity of about 10 milligrams. It was found to be zero below about 60 per cent of natural length. HILL (3*f) reports above 65 per cent of it* natural length the latent period of a toad's sartorius is constant, showing that the muscle does not lengthen in relaxation. For this experiment the muscle must be free of any load because a slight force draws it out after contraction. KATZ (35) writes on the speed of action and the power of muscles, pre- senting one of the more interesting problems of physiology, the ultimate ex- planation of which will depend upon a thorough knowledge of the contractile material and especially of the physical and chemical properties of the long chain protein molecules embedded in muscle fibers. Two forme of myography are presented by GORDON and HOLBOURN (36) which permit the simultaneous recording of the contractions and the action poten- tials of single motor unite. The experiments are performed on the crureus (stimulated hy stretch reflex or by crossed extension reflex) and the tib- ialis anterior muscle (stimulated by the spinal flexion reflex) of decere- brate cats. The average contraction time (measured from the origin of the twitch to its peak) for single twitches in the crureus Is 60.9 £ 1.18 milli- seconds, in the subcutaneous fibers of the tibialis anterior 28,9 £ 0.65 milliseconds, and on the deep and distal surface of the same muscle 62.6 £ I.63 milliseconds. Thus this latter muscle similarly to extensor muscles, contains a mixture of superficial quick and deep-slow fibers. A single mo- tor unit under the influence of very slight reflex excitation, gives single isolated twitches. Usually, however, there is a greater or lesser fusion between individual twitches. No complete tetanic fusion of the twitches of a single motor unit was observed, partly owing to the small stimuli; but there is a complete fusion of two twitches when the motor neuron gives a double discharge, occurring mostly at the beginning of a reflex contraction. The total tension developed in this case is rather more than twice the ten- sion of a single twitch. Clearly, this double discharge allows a large de- velopment of tension. ZINGONI (37) discusses fluctuations in excitability of muscle by means 60 of an inductor with Kronecker elide or an electronic stimulator, with non- polarizable electrodes; the isolated gastrocnemius of the frog was stimulated liminally or just supraliminally. Rhythmic contractions of low frequency (40 per minute) were observed. It was noted that the height of the indivi- dual muscle twitch varied considerably in most cases. These fluctuations disappeared after curarization but persisted after paralysis or degeneration of the motor nerve. In the study of metabolic biochemistry. HERMAIW et al (38) report the fact that there is a greater adenosinetriphosphatase activity in developing muscles than is warranted by the increase in myosin proteins. They homogen- ized the muscle of rat embryos and fetuses and fractionated this into four parts. One fraction was found to have the purest preparation of myosin and the ATP activity was noted to be six times greater in this than in the other fractions. GASP® et al (39) state that 41 urinary creatine-creatinine determina- tions of 34 diabetic clinic subjects show that these excretions were in- creased as compared with normal controls. IBiose diabetics with fibrillary muscular activity manifest an average creatine index more than 3? times that of the normal controls. This marked increase in creatine excretion appears to be a part of the diabetic syndrome. The extent of this increase seems to correspond to a condition of muscular degeneration. MIIKDT and GRIMES (40) show that urinary excretion of pentose and phos- phorous-containing complexes occurs in nutritional muscular dystrophy pro- duced by a vitamin E deficient diet. The significance of urinary excretion of these substances in nutritional and in clinical muscular dystrophy can- not, at present, be evaluated. ZIEELTER et al (*fl) report an investigation of several causes of crea- tlnorla. They found that in Cushing's disease, during the puerperium, dur- ing administration of desoxycorticosterone acetate and with administration of thyroid to patients with hypothyroidism the resorption power of the renal tubules was reduced and creatinaria followed. Another method, (possibly in- creased synthesis and glomerular filtration) was associated with administra- tion of methyltestosterone. A reduction in muscle mass, as in an old ease of poliomyelitis, failed to give adequate bulk for proper creatine disposi- tion with resulting increased renal excretion. Finally it was felt that anomalous absence of creatinuria in patients with myotonic dystrophy may be secondary to reduced synthesis. The authors felt that the creatin coeffi- cients and serum concentrations were functions of both active muscle mass and glomerular filtration rate. Eleven authors write on physiological biochemistry. Among these, CREESE (42), using normal and denervated rat diaphragm muscle, reports a study of the action of carbon dioxide-bicarbonate buffer on tension and con- traction height and found that the presence of bicarbonate was necessary for normal twitch tension. HDEBIGrER (43) finds that in high concentrations physostigmine produces contraction of the frog's rectus muscle in which cholinesterase has been completely Inactivated by tetraethylpyrophosphate. Anticholinesterases an- tagonize the blocking action of curare on acetylcholine, not of other excl- 61 tants like nicotine. FATT (44) gives the results of his studies on the depolarising action of acetylcholine on muscle. The region of greatest density of motor nerve endings in a frog sartorius was determined by finding the region of great- est depolarization produced hy a solution containing physostlgmlne and ace- tylcholine. Depolarization and contraction were greatly reduced after bath- ing the tissue in Singer*s solution in which NaCI was replaced by glucose. The response to KC1 was not abolished by lack of NaCI. PBPTKD and STRAW (45) report an analysis of action of adenoslnetri- phosphate and of boiled muscle extracts on the quinine treated Isolated frog heart in which they found that the active substance in muscle extracts which restores normal function of the heart is identical with adenosinetriphos- phate which in the tissues is never completely broken down. A constant per- centage of the total adenosinetrlphosphate of skeletal muscle liver and kid- ney is never split by the tissue enzymes even on prolonged standing. TMs fraction is believed to be bound to proteins as adenosinetrlphosphate. A flavone isolated from lucerne by FERGUSON et al (46) is discussed. It was found to initiate smooth muscle movements, like other flavonea. Pur- ification has shown it to be tricln. Certain lucerne flavone preparations, however, were found to possess greater activity on smooth muscle movements than the purified isolated tricins. JACOBI et al (4?) find that malic dehydrogenase, cytochrome oxidase, succinic dehydrogenase, lactic dehydrogenase, furaarase, and adenoslnetri- phosphatase activities in muscle (gastrocnemius) homogenates from rabbits with incipient nutritional muscle dystrophy are the same as in homogenates from normal animals. The same is true for uricase and adenosinetriphospha- taae activities of liver homogenates from normal or dystrophic rabbits. QOHDAN et al report that testosterone propionate did not affect the atrophy of the anterior tihial muscle of the rat following denervation. The testosterone treated animals, however, lost less body weight following the operation than did the untreated animals. There was no difference in the length tension relationships when compared on the basis of cross section- al areas in the treated and untreated groups. It is concluded from these studies that testosterone offers little or no promise in the treatment of the atrophy of denervated skeletal muscle. Crotonoside (isoguanosine) is shown by ESflNGr et al (49) to be much more active than adenosine in reducing the blood pressure in rabbits and cats, in decreasing the tone of isolated intestinal strips of the rabbit, guinea pig, and hamster and ir stimulating the isolated uterus of guinea pigs and hamsters. The difference in activity of these two compounds is considerably more marked with the guinea pig tissues than with those of the rabbit, cat, or hamster. Possible relationships to theories of action of adenosine are discussed. FONTAINE et al (50) produce Volkmann*a contracture by injecting tenel- eryl into the brachial artery of dogs. They conclude that the sympathetic chain does not participate in this reflex. fHie drug seems to act directly on the muscle tissue. 62 JAR CEO et &1 (51) report that bis-trimethylammonlom decane (C °) de- presses markedly the twitch tension of innervated rat muscles and causes asphyxlal death unless respiration is artiflcally maintained. Depression occurs without change in the action potential of motor nerve or in the cap- acity of muscle to respond to direct stimulation. reduces end plate po- tential below the amplitude necessary for initiation of a propagated electri- cal response in muscle fibers. LORSTI (52) reports on his study of the zonal precipitations, in par- allel laminae, obtained in glass tubes, attaining the diameter of 0.4 milli- meters. The reactions have taken place sheltered from light and at temper- atures varying between 15 and 30 degrees centigrade. The salts placed in contact, dissolved in distilled water or in watery or formollc agar, were: silver nitrate, potassium chromate, sodium iodide, chloride, and bromide, calcium chloride and disodic phosphate, variously associated. The compari- son of the Images thus obtained with those offered by the organization in transversal strips of the striated muscular fiber, in the muscles both of the wings and of the legs in some insects, shows a suggestive analogy at least formally. Nevertheless, on the grounds of the investigation made by him, the author arrives at the following conclusions that no genetic or structural correlation can exist between the two orders of facts; that the topographical and spatial analogies between the zonal laminae and the trans- versal strips (or striae) of the muscle fiber are merely apparent; that the "rhythmic” distribution of components of various nature along the myofibrll- lae depends on more complex and various mechanisms than the ones applied in the determination of the salt precipitations in vitro. The definite organ- ization of the myoflbrlllae, and therefore of the striated muscle fiber, must be connected with the interaction of complex factors, not only of chem- ical or physiochemlcal but functional nature, variously coordinated and com- bined and acting in a colloidal medium endowed with life and eminently plas- tic. Two authors discuss muscle relaxants. In a survey by MDSHIN (53) at- tention is drawn to the essential differences in mode of action between D- tubocurarine chloride, "Flaxedll" - a synthetic tubocurarin© substitute - and decamethonium Iodide (C^0, eulissln, syncurlne); the former two are an- tagonized by prostigmine but the latter Is unaffected by this compound, be- ing antagonized by hexamethonlum bromide The action of curare is to block voluntary muscle stimulation by acetylcholine; prostigmine causes an accumulation of acetylcholine by preventing its destruction, thereby over- coming the curare barrier. The exact site of action of hexamethonlum iodide is not known. The value of curare in anesthesia is stressed and other uses of curare in tetanus, spastic diseases, and electroconvulsion therapy are mentioned. HARRIS and DRIPPS (54) discuss the use of decamethonium bromide as a muscular relaxant in 250 surgical patients. Its dosage, physiological ac- tions, and use with anesthetic agents are presented. Decamethonium bromide was found to be freely miscible with pentothal and to have no histamine re- actions. Skeletal System Osteogenesis is the development of bones. Experiments on osteogenesis In rabbits by VACHSMUTH (55) support the findings of Annersten (19**0)* The osteogenetic substance obtained by extraction of bone tissue Is probably formed In the tissue surrounding the fracture and is not Identical with the substance found In the urine* Concentrated alcoholic extracts of the varl- ous components of a long bone gave the following results: marrow extracts 71 per cent positive, cortex extracts 61 per cent, periosteum extracts 53 per cent, Id day old callus 43 per cent, whole bone extract 92 per cent* The partial extracts caused the formation of cortical bone only* The newly formed bone Is slowly absorbed* * In observations on the organic matrix of bone, ROGERS (56) states that concentration of total nitrogen in the bone tissue was found to fall with age (as anticipated by previous investigators). The amount of reducing sub- stances also showed considerable decrease* Ground sections of bone stained by the method of Hotchkiss for demonstrating polysaccharides showed high con- centrations of the material in the haverslan canals and very low concentra- tions in the substance of the bone matrix* Im order to increase understanding of the general syndrome of pyorrhea, a study of the metabolism and structure of alveolar bone was undertaken by WEIDMANH and ROGERS (57)* The rate of exchange of radioactive phosphorus was investigated in cats* The phosphorus entered the bone salt of the trabecular alveolar bone at a rate very much less than the corresponding rate for the trabecular bone of the epiphysis and a little greater than that for the shaft of the long bone* HAHOOX (58) by the motion picture technique, finds that osteoclasts have an undulating peripheral membrane in tissue culture, and that they form fine cytoplasmic filaments* Because of this, it was felt that osteoclasts may be related more to wandering cells than to osteoblasts* Embryonic rat femora were cultivated In a circulating medium composed of equal parts of pregnant rat serum and rat embryonic extract by MITCHELL (59)* The rate of growth is very slow, when compared with growth In utero* Limb buds of 13 day old embryos differentiate into cartilage and connective tissue* The 17 day femora showed perichondral ossification and differentia- ted condyles and trochanters* The 18 and 19 day femora had both perichondral and enchondral ossification* Three authors discuss anatomy of the skeletal system* MacCOHAILL (60) reports a study of the movements of bones and joints. He finds that synovi- al fluid acts mechanically by forming a conveyant lubricant film between the fixed and the moving joint surfaces* The fatty pads assist lubrication by reducing the mechanical curvature of joint with more highly curved surfaces* The intraarticular discs and menisci increase the mechanical curvature in joints with surfaces of small curvature* Sesamoid bones exert bow-string pressure upon the bones with which they articulate* ETTER (6l) reports that roentgenograms of the disarticulated skull present a confusing labyrinth of superimposed lines and shadows* In order to separate these from one another and discover the exact details contribu- ted by the various component bones, disarticulation of the dried skull was undertaken. Then by filming each component bone at first separately in the various standard positions and next with it in the skull it became possible 64 to correlate features found In the detailed analysis of the Isolated hone with contiguous structures. ASCENZI (62) discourses on the existence of bonds between ossein and inorganic bone fraction. The problem of the existence of these bonds is as yet unsettled. Cagllotl has shown that the bone x-ray pattern gives evi- dence of the existence of a semicombined lattice formed by ossein and the in- organic fraction. In the articles on biochemistry of the skeletal system, PAFP and SNIF- TER (63) report on the effect of hyaluronidase on bone growth in vitro. Paired femora were dissected from some 60 chick embryos of six to nine days incubation and cultured for two to seven days. Those intermittently sub- jected to 0.6 per cent hyaluronidase-Tyrode solution grow less than the con- trols but bone formation was not delayed. Decreased basophilia in the treat- ed femora is interpreted as indicating hydrolysis of chondroltln sulphuric acid by the hyaluronidase, suggesting a mechanism for the removal of hyaline cartilage during bone formation. MANNIPO investigating alpha-aminovalerlanlc acid (Norvalln) in the evolution of the fracture callus treated rabbits with experimental frac- ture of the radius with daily subcutaneous injections of norvalln. By com- parison with a control group it appeared radlologlcally and histologically that healing in all its stages was accelerated by approximately 10 days. To determine changes in endochondral ossification of the tibia accom- panying acute pantothenic acid deficiency in young rats NELSON et al (65) maintained rats on a pantothenic acid-deficient diet from birth until they were moribund (three to 16 weeks). The histological changes in the tibia indicate that there is a severe disturbance in structure and that growth of the tibia is retarded. It is concluded that pantothenic add is essential for stimulation and maintenance of normal chondrogenesis, osteogenesis, and haemopoiesis in the rat. The diet used in this study was also deficient in biotin and folic acid. In an account of the use of tannin in arthroplasty PROVUNZALB and PAR- IENTB (66) "bathed the cancellous hone of dogs, after removal of the articu- lar cartilage of the knee Joint in a 10 per cent solution of tannin in di- lute alcohol, with a resulting absence of ankylosis. In guinea pigs the same solution was injected around experimental diaphyseal fractures with the resulting absence of callus. Sex differences in the fat/hone index are described by REYNOLDS (6?) in a series of 505 children and adults. The index is defined as the relation of breadth of the fat to breadth of bone as seen in a roentgenogram of the leg. The index tends to decrease with age in males and increases with age in females. The mean index is higher in females at each age level studied. In the adult, the fat/hone index differentiates the sexes with 90 per cent accuracy. A close association between fat/hone index and body build was ob- served. Miscellaneous ALTSMEIER et al (68) report that aureomycin and Chloromycetin seem to 65 prevent gas gangrene In guinea pigs* HOLBROOK and PILCHER (69) report the results of their study of the ef- fects of penicillin, peanut oil, and beeswax separately and in combination upon nerve and muscle tissue of dogs* Injections of these materials into sciatic nerve and hamstring muscles revealed occurrence of pathologic chang- es* Calcium penicillin in oil and wax produced marked changes while the peanut oil alone produced only mild changes. A case of degeneration of ra- dial nerve and surrounding muscle tissue in a man following injection of penicillin in oil and wax is cited* 66 BIBLIOGRAPHY 1, Seifter, J,, Baeder, D. H., and Gegany, A. J.; Influence of hyalur- onidase and steroids on permeability of synovial membrane, Proc. Soc, Exp. Biol., F. Y., 72; 277-82, Bov 19^9 2, Sprague, H. G,, Power, M. H., Mason, H. L., Albert, A., Mathieson, B. R., Reich, T, S., Kendair, E. C., Slocumb, C. 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Physiol,, Lond., 110: Proc, 6, Dec 15, 1949 33* Hill, A, V,, and Parkinson, J. L,: The resting tension of muscle, J, Physiol., Lond,, 109: Proc. 8, Sept 1949 34. Hill, A, V.: The absence of lengthening during relaxation in a com- pletely unloaded muscle, J, Physiol,, Lond,, 109: Proc, 8, Sept 1949 35* Katz, B,: Electrical properties of muscle fibre, Research, Lond,, J: 359-65. Aug 1950 36. Gordon, G,, and Eolboum, A, E. S,: The mechanical activity of single motor units in reflex contractions of skeletal muscle, J. Physiol,, Lond., 110: 26-35, Dec 15, 1949 37* Zlngonl, U,: Fluctuations in excitability of the striped muscle fiber to stimuli of threshold intensity, Arch, flsiol., 49: 182-92, Mar 3* 1950 38, Herrmann, H,, Nicholas, J. S., and Vosglan, M, E,; Liberation of in- organic phosphate from adenosinetriphosphate by fractions derived from developing rat muscle, Proc. Soc, Exp. Biol., N, Y., 72; 45**-?, Nov 1949 39* Caspe, S., Davidson, B., and Truhlar, J.: Creatine-creatinine indices of diabetic subjects and effect of muscular degeneration. Am, J, Phys- iol., 159 : 461-6, Dec 1949 40, Minot, A, S., and Grimes, M,: The urinary excretion of pentose and phosphorus containing complexes in nutritional muscular dystrophy, J, Nutrit,, 39: 159-65, Oct 10, 1949 41, Zierler, K. L,, Polk, B. P,, Magladery, J, V,, and Lllienthal, J. L,, Jr,: On creatlnuria in man; the roles of the renal tubule and of mus- cle mass. Bull. Johns Hopkins Eosp,, 85: 370-95, Eov 1949 42, Creese, R,; Bicarbonate ion and striated muscle, J, Physiol,, Lond,, 3.10: 450-7, Dec 1949 43, Eebbiger, F.: The action of anticholinesterases on striated muscle, J, Physiol,, lond,, 109: Proc, 28, Sept 1949 69 44. Fatt, P.: The depolarizing action of acetylcholine on muscle, J. Physiol., lend., 109: Proa 10, Sept 1949 45i Pettko, E., and Strauh, P, B.: The active principle of muscle ex- tracts increasing the performance of the hypodynamic frog’s heart, ad- enosinetriphosphate, Hungar. acta physiol., 2: 114-9, 194-9 46. Ferguson, ¥. S., Ashworth, D., and Terry, R. A.: Identity of a mus- cle-inhibiting flavone in lucerne, Mature, London, 166; 116-7* July 15* 1950 4-7* Jacobi, H. P., Rosenblatt, S., Wilder, V, M., and Morgulls, S.j Ih- zyme studies on rabbits with incipient muscle dystrophy. Arch. Biochem., 27! 19-21* Jane 1950 48. (Jordan, &. S., Felnsteln, B., and Ralston, H. J.; Effect of testos- terone upon atrophy of denervated skeletal muscle, Exp. M. & S., 7! 327-34, Not 1949 49. Ewing, P. L., Schlenk, F., and Emerson, 0, A.: Comparison of smooth muscle effects of crotonoside (Isoguanosine) and adenosine, J. Pharm. Exp. Ther., 97 : 379-83* Nov 1949 50. Fontaine, R., Kayser, C., Klein, M,, Marx, C., and Bany, A.: Physio- logical and morphological modifications of the striated muscle follow- ing intra-arterial injections of iodo-organlc product into the humoral artery of the dog-experimental Kolkmann’s contracture. Rev. chlr.. Par., 69: 15-36, Jan-Feb 1950 5!• Jarcho, L. ¥., lyzaguirre, C., Talbot, S. A., and Lilienthal, J. 1., Jr.s Neuromuscular excitation; responses of normal and denervated mammalian muscle to bls-trimethylajamonium decane (C10) and to 0-tubo- curarine. Am. J. Physiol., 162; 475-88, Aug 1, 1950 52. Loreti, F.: Correlations between transverse striatlon of muscle fiber and the laminae of rhythmic precipitation, Riv. blol., 42; 3-26, Jan- Kar 1950 53* Mushin, W, Muscle relaxants, Practitioner, lond., 164: 270-5* Mar 1950 54. Harris, L. C., and Drlpps, R. D.: The use of decamethonlum bromide for the production of muscular relaxation. Anesthesiology, 11: 215- 23, Mar 1950 55* Wachsmuth, (J*; Experimental contribution on the causal problem of osteogenesis. Arch. Klin. Chir. (lengenbeck's), 265 : 58-68, Apr 24, 1950 56. Rogers, H. J.: Observations on the organic matrix of bone, Biochem.. J., Lond., 45: xxiv, 1949 57* Weldmann, S., and Rogers, F. J.: Preliminary observations on the me- tabolism of the alveolar bone of mammals, Biochem* J., Lond., 45: xxv, 1949 70 58. Hancox, F. M,: Motion picture observations on osteoclasts in vitro, J. Fhysiol., Lond., 110: 205, Dec 15, 1949 ♦ 59* Mitchell, J. R.: Growth of embryonic rat bone In circulating medium, Anat. Rec., 106: 111-4, Jan 1950 60* MacConalll, M. A.: The movements of bones and joints; the synovial fluid and Its assistants, J* Bone Surg., 32 Bi 244-53* May 1950 61. Etter, L. E.: X-ray studies of the disarticulated skull, N. York State J. M., 49: 2808-10, Dec 1, 1949 62. Ascenzl, A.: On the existence of bonds between ossein and inorgani trophrenic respirator cannot be considered established in bulbar poliomye- litis until additional experience has been obtained, but the foregoing data are encouraging. The apparatus should not be used unless the operator has acquired sufficient proficiency in its use* However, practice on normal volunteers is readily acquired* The electrophrenic respirator is seen to diminish considerably and strikingly the restlessness and hypertension in one patient and achieve similar results in others* The mechanisms involved are not known. It is thought that nursing care is facilitated in the treated group of patients in comparison to what is usually the case with tank-en- closed patients* HANSSON (4?) takes up the care of upper extremity paralysis in polio- myelitis. He stresses the followings (a) the principal therapy for the aft- er-effects of poliomyelitis anywhere is to release spasm, support and strength- en weakened muscles, and prevent deformity, (b) it is especially necessary to use the proper brace in cases of paralysis of serratus magnus and deltoid muscles, (c) electrical stimulation is indicated when one muscle or a small muscle group is paralyzed, and (d) weight lifting exercises are recommended for increasing strength of muscles. Physical medicine measures used in the Los Angeles County Hospital during the 1948 poliomyelitis epidemic in cases of respiratory patients are described by AUSTIN et al (48). They discuss the use of packing, position- 80 ing, and muscle re-education in a large series of cases. The care of pa- tients and respirators is also discussed at considerable length. AUSTIN et al (49) also discuss the administration of the physical medicine department at the Los Angeles County Hospital during that epidemic with particular em- phasis upon the ratio of patients to therapists, training methods for pack- ers, department supervision, patient disposition and follow-up, and home as- sistance hy public health nurses. His findings on •prognosis in poliomyelitis are compiled by LMHAHD (50). He compares a survey of the epidemic of poliomyelitis in Maryland, in- cluding data concerning the incidence, the mortality, and age, sex, and the types of the disease, with a survey of the epidemic in Maryland. The results of the two epidemics are similar, slightly more patients with resi- dual involvement being seen in • Good recovery is recorded for approx- imately 80 per cent of the patients, and, apparently, treatment aids in at- taining maximum recovery. Delay in recovery and persistence of weakness are observed in patients allowed to fatigue muscles by over-treatment, too much activity, or lack of necessary support. Treatment given without regard to the protection of muscles results in a greater degree of residual involve- ment and more deformities. The preceding represents a two-year follow-up study. 81 BIBLIOGRAPHY 1* Scobey, R. R.; Epidemic apoplexy and poliomyelitis, a contribution to the history of infantile paralysis. Arch, of Pediat., R. Y., 67: 29- 46, Jan 1950 2. Kessel, J. F., and Plait, C. R.: Immunologic groups of poliomyelitis viruses. Am. J. Hyg., $!'• 76-84, Jan 1950 3. Poliomyelitis following innoculation (Report of Societies), Brit. M, J., 4660: 1004-5, Apr 29, 1950 4* Ward, R», Rader, D., Lipton, M. M.# and Freund, J.; Formation of neu- tralizing antibody in monkeys injected with poliomyelitis virus and adjuvants. Proceedings Society of Experimental Biology, R. T., 74: 536-9, July 1950 5. Dick, 0* ¥. A.: Persistence of Brunhilde poliomyelitis virus in rodent brain without evidence of adaptation, Proc* Soc. Exp. Biol., R. Y., 74: 591-4, July 1950 6. Hurlburt, H. S.: The recovery of poliomyelitis virus after parenteral introduction into cockroaches and houseflies, J. Infect. Dis., 86: 103, Jan-Feb 1950 7* Rhodes, A. J., Clark, E. M., Knowles, D. S., G-oodfellow, A. M.# and Donohue, W. L.; Prolonged survival of human poliomyelitis virus in experimentally infected river water, Canad, J. Pub. Health, 41: 146- 9, Apr 1950 8* Rhodes, A. J., Clark, E. M., Knowles, D. S., Shimada, F., Coodfellow, A. M., Ritchie, R. C., and Donohue, V. L.: Poliomyelitis virus in ur- ban sewage; an examination for its presence over a period of 12 months, Canad. J. Pub. Health, 4l: 248-54, June 1950 9* Armstrong, M, P#f Wilson, F, H,, et al: Studies on poliomyelitis in Ontario; isolation of the Coxsackie virus in association with polio- myelitis virus; a preliminary report, Canad. J. Pub. Health, 41; 51- 9, Feb 1950 10. Faber, H. K., Silverberg, R. J., and Dong, L.: Studies on entry and egress of poliomyelitis infection. II. Entry and spread after exposure of the trigeminal nerve, J. Exp. M., 91i 549-60, May 1, 1950 11. Earl, A. A.; Serum potassium in poliomyelitis, J. of Pediat., St. Louis, 36: 715-720, June 1950 12. Kelley, V, C., Doeden, D., et al: The beta disturbance of the electro- phoretic pattern of blood serum in poliomyelitis, J. Pediat., St. Louis, 35: 752-9, Dec 1949 electrical 13* Brown, F. M,, and Bruesch, S. R.: Patterns of increased/skin resis- tance in acute human poliomyelitis, Arch. Reur. & Psychiat., Chic., 62: 82 766-77. Dec 1949 14, Clinical-pathological conference: poliomyelitis, Arch, Pedlat,, 67: 184-7, Apr 1950 15, Baskin, J, L., Soule, E, H,, and Mills, S, D.: Poliomyelitis of the newborn; pathologic changes in 2 cases, Am, J. Dis. Child,, 80; 10- 21, July 1950 16, Silverthrone, N., Goodfellow, A, M., and Anglin, C.: Poliomyelitis: a clinical, epidemiologic and laboratory study, Am. J. Dis. Child,, 79: 947-9• May 1950 17• Greenberg, M,, Siegel, M., and Magee, M, C.j Poliomyelitis in New York City, 1949, N. York State J. M,. 50: 1119-23, May 1, 1950 18, Blum, H. L,, Chiapella, W, C., and Lesem, A, M.; The 1948 epidemic of poliomyelitis in San Diego County, California, Stanford M. Bull,, 7: 169-79, Nov 1949 19* Geiger, J, C.; Poliomyelitis in San Francisco, 1948, Am. J. Pub. Health, 39: 1567-70, Dec 1949 20. Wegman, M. E,; Average incidence and epidemic recurrence of poliomye- litis, Pediatrics, Springfield, 5: 357-61, Peb 1950 21. Hammon, ¥,: Present state of the poliomyelitis problem on the Ameri- can hemisphere, Medicina, Hex., 30: 113-6, Aug 10, 1950 22. Poliomyelitis, lancet, 2: 268, Aug 12, 1950 23* Poliomyelitis (Epidimiological notes), Brit. M. J,, 2: 532, Aug 26, 1950 24, Hargreaves, E, R,; Poliomyelitis in Cornwall in 19*<9, Brit. M, J., 4658: 879-03, Apr 15, 1950 25* Logan, W. P, D.: Poliomyelitis, 1949; preliminary observations, Lan- cet, Lond,, 2: 1006-9, Nov 26, 1949 26, Southcott, R. V., Crosby, N. D., and Stenhouse, N, S.: Studios on the epidemiology of the 1947-1948 epidemic of poliomyelitis, Med, J, Australia, 2: 481-96, Oct 1, 1949 27* Ward, R.; Some recent advances in poliomyelitis, J. Pediat., S, Louis, 37: 263-70, Aug 1950 28. Bower, A, G.: A concept of poliomyelitis based on observations and treatment of 6000 cases in a 4 year period, Northwest M., 49: 103, Peb 1950 29. Bower, A, G,: A concept of poliomyelitis based on observations and treatment of 6000 cases in a 4 year period. Northwest M,, 49; 187-90, Mar 1950 83 30. Kelleher, V. E.: Poliomyelitis, Brit. M. J., 2; 570-3, Sept 2, 1950 31. Horstmann, D, M,; Acute poliomyelitis, relation of physical activity at the time of onset to the course of the disease, J. Am. M, Ass., 142: 236-41, Jan 28, 1950 32. Curnen, E. C,t Shaw, E. W,, and Melnick, J. L.: Disease resembling non-paralytic poliomyelitis associated with a virus pathogenic for in- fant mice, J. Am. M. Ass., l4l: Nov 26, 1949 33• Ahhot, A. P.; The diagnosis of poliomyelitis, Med, Clin. N. America, 34: 119-32, Jan 1950 34. Vogel, E.: Recognition, treatment and control of poliomyelitis, N, England J. M., 242: 899-908, June 8, 1950 35* Ransohoff, N. S,: The treatment of anterior poliomyelitis, Med. Clin. N. America, 34: 553-62, Mar 1950 36. Stlmson, P. M.: Some debated points in the treatment of acute polio- myelitis, J. Pedlat., St. Louis, 36: 704-10, June 1950 37* Applebaum, E., and Saigh, R.: Aureomycin in the treatment of polio, J. Am. M. Ass., 143: 538-9» June 10, 1950 38. Stone, S.: Treatment of anterior poliomyelitis; report on intraspinal administration of pyridoxlne and thiamine hydrochloride and artificial fever therapy, Arch. Pediat., N. T., 66 : 443-61, 1949 39* Pox, M, J,, and Hornberger, E. Z., Jr.: Phenosulfazole (darvisul) in acute poliomyelitis, J, Am. M, Ass., 143: 535-8, June 10, 1950 40. Reilly, V. A., and Barsant, A. ¥.; Prlscoline for pain in poliomye- litis, J. Pedlat., St. Louis, 36: 711-714, June 1950 41. Geisler, W. 0., Mustard, W. T., end Anglin, 0, $.• The treatment of pain and "spasm" In poliomyelitis with "prlscoline," Canadian M. Ass. J., 63: 60-3, July 1950 42. Guyton, A. C., and Reeder, R. C.; Pain and contracture in poliomye- litis, Arch. Neur. & Psychiat., Chic., 63: 95^—63, June 1950 43. Harmon, P. E.; Surgical reconstruction of the paralytic shoulder by multiple muscle transplantations, J. Bone Surg., 32 A: 583-95* July 1950 44. Thomas, L. I., Thompson, T. C., and Straub, L. R.: Transplantation of the external oblique muscle for abductor paralysis, J. Bone Surg., 32 A: 207-17, Jan 1950 45. Plorian, M,; Equalizing of the length of lower extremities, Lek listy, 5: 279-84, May 15, 1950 46. Sarnoff, S, J., Maloney, J. V., Jr.,•Sarnoff, L, C., Perris, B. G., Jr., 84 and Vhittehberger, J. L.: Electrophrenic respiration in acute "bulbar poliomyelitis; its use in management of respiratory irregularities, J. Am. M. Ass., 1383-90, Aug 19, 1950 Hansson, K. G,s Care of upper extremity paralysis in poliomyelitis, Arch. Phys. M., 31: 387-92, June 1950 48. Austin, E., Huddleston, 0. L., and Bower, A. G.: Physical medicine procedures in the care of respirator patients; measures used in the Los Angeles County Hospital during the 1948 poliomyelitis epidemic. Arch. Phys. M., 31; 76-8O, Peh 1950 49. Austin, E., Huddleston, 0, L., end Bower, A. G.: Administration of the physical medicine department, Los Angeles County Hospital during the 1948 poliomyelitis epidemic. Arch. Phys. M,, Jl: 71-4, Feb 1950 50. Lenhard, H, E.: Prognosis in poliomyelitis, J. Bone Surg., 32 A: 71~ 9. Jan 1950 85 CHAPTER VII NEUROMUSCULAR DISORDERS EXCLUSIVE OP POLIOMYELITIS By Chalmers R, Carr, Commander, (MC), USN U, S, Naval Hospital Bethesda, Maryland Assisted By C, A. Stevenson, GDR, (MC), USN J. I. P. Xnud-Fansen, LCDR, (MC), USN A. W. Dunn, IT, (MC). USN J. R. Walker, LT, (MC), USNR R. Iusskin, LT, (MC), USNR D, 0, DuVigneaud, CDR, (MC), USN W. P. Strong, IT, (MC), USNR V. C. Brady, IT, (MC), TJSN W, S. Foultz, LT. (MC), IJSNR R. 0. Xindred, IT, (MC), USNR M. F, Jahss, LT, (MC), USNR I* Cerebral palsy A, General B, Drag treatment C, Orthopedic treatment II, Myopathies A. Congenital B, Myasthenia gravis C, Atrophies and dystrophies D. Miscellaneous III, Nervous system disease of various causes A, Multiple sclerosis B, Paralysis agltans C, Gulllan-Barre syndrome IV, Traumatic infections and toxic lesions A, General B, Peripheral C, Spinal cord D, Brain V, Pain A. General B, Miscellaneous There are 144 articles represented in this chapter, selected from the 164 which were considered. Cerebral Palsy Seven abstracts are Included under general discussion of this disease. 86 GAUGER (l) studies cerebral palsy as to ratio of Mrths, etiology, major forms, mental deficiency, other defects, and physical disability. Treatment should he conducted hy a physician trained In the problems of the cerebral palsied. According to the author, this article forma a good compendum of the subject for the casual reader. GIDEH (2) states that the cerebral palsied should be taught the Impor- tance of neat personal appearance, self expression, interest In the outside world, religious faith and to be accepted by the community. A survey of cerebral palsy patients In Schenectady County by LE7HT et al (3) indicates that the incidence of this disease is 5»9 per 1000 live births, and the prevalence is 152 per 100,000 population. Financial strain is evident in all but the highest economic levels. 2? per cent of the pa- tients, five years of age or older, have never attended school, and por cent require special classes or institutional care, 62 per cent of the pa- tients, 20 years of age or older, have never been employed, and 1? per cent are employed either irregularly or on a part-time basis. The Schenectady County survey indicates that 9»0 per cent of cerebral palsy patients require no services, per cent need services on an ambulatory basis, 8,3 per cent require prolonged medical treatment at a hospital-school, and 18,6 per cent should be placed in institutions for custodial care. From an etiological standpoint, GATOER presents a statistical sur- vey of a group of institutionalized cerebral palsy patients, and finds that nearly per cent are first born or born after an interval of 10 to 15 years, and he concludes from the survey that birth order may play an important part in the etiology of cerebral palsy; that intelligence and physical handicap may vary widely even in a group of mentally defective cerebral palsy patients; and that in this group, epilepsy is an important factor. The medical considerations and classifications of cerebral palsy are presented by FAY (5), The chief recognized causes of cerebral -Daisy are as follows: (a) birth trauma, (b) RH factor, (c) hypoxia, (d) virus infections, (e) meningitis, (f) tumors, (g) congenital anomalies, (h) defects in circula- tory or spinal fluid mechanisms, and (l) systemic factors that secondarily affect the normal functions of the brain, A classification table was pre- sented: (a) spastic paralysis - cerebral, (b) athetosis - mid-brain, (c) tremors and rigidities - basal ganglia, (d) ataxia, (e) high spinal spastic - medulla, (f) mixed - diffuse, (g) emotional release, (h) head, neck, arm, (i) shuider type, (k) rotary type, (l) dystonic type, and (m) flail type. Early diagnosis of cerebral palsy is discussed in general terms by AGASSIZ et al (6) with comparison of development of normal infants, and those with brain damage. They describe a number of reflexes which are of aid in diagnosis. MALZBERG (?) analyses cases of cerebral palsy with mental defi- ciency, 82 per cent are either imbeciles or idiots and 15 per cent were morons. The racial distribution indicates a probably excess of Hebrews. There is a probable excess of later born also. In an article on treatment of the hopeless cerebral palsied patient HIPPS (8) defines the hopelessly paralyzed cerebral palsy patient and states 87 that the chronology of motor skills learned hy the normal patient can ho tabulated in order of importance for the development of self sustaining in- dividual* Drug treatment of cerebral palsy is considered. MICHAIL (9) reports the use of curare in the form of nintocostrip" in 1? children, ages two to 16 years, with spastic syndromes. The dosage is 0.5 units per kilogram for the first injection and 0.75 units per kilogram in subsequent Injections, intramuscularly, once per week* In 10 cases, complete relaxation of the stri- ated musculature was seen; in five, the effect appeared more slowly; and in two, no improvement was seen. The relaxation appeared after 20 to 30 minutes and was total after an hour; its duration, two to three days. During this period, the physiotherapists work was facilitated. THTOFSEN and CHRISTENSEN (10) recount their experiences with curare in spastic conditions. They list the preparations of curare and data for the estimation of the effect. The authors conclude that curare therapy cannot replace the physlurgic and orthopedic treatment, but it may serve as a sup- plement to such treatment. HIPPS (11) describes administration of tolserol (3-orthotoloxy-I, 2- propanediol) to 19 cerebral palsy children in an effort to determine its value as a therapeutic agent. The author says that in 12 of the 19 patients, the mothers thought the children had improved. In per cent of the pa- tients tested, tolserol produced increased muscle relaxation, but in only 16 per cent was there any Improvement in muscle control. Another 16 per cent showed a decrease in muscle control* FRANTZ (12) reports oral tolserol to be well tolerated over a seven month period in 23 of 2? children with cerebral palsy. Children with spas- ticity and rigidity are not reported to respond satisfactorily in the group evaluated. On 16 athetoid children, demonstrate beneficial effects. Children over 10 years of age seem to respond better than the younger sub- jects. The opinion of the speech instructor and physical and occupational therapists is that the drug certainly deserves a trial in the athetoid group. PFRLSTFIN and BARNETT (13) evaluate neostigmine therapy in cerebral palsy in 60 patients. Only three of the cases can be said to have shown im- provement. The authors conclude that neostigmine therapy has not shown suf- ficient specific benefit to merit routine use in any form of cerebral palsy and that it may be wise to allot a greater portion of the general treatment to psychiatric therapy. As regards orthopedic treatment of cerebral palsy, surgical division of the patellar retinacula to improve extension of the knee joint in cerebral spastic paralysis by EGGERS (Ik) is a well thought-out solution to a common problem. In flexion contractures of the knee joint due to spastic paralysis, the quadriceps tendon is stretched and prevented from fully extending the knee, because the less stretched fibrous and muscular retinacula on the med- ial and lateral side of the knee joint prevent full extension. Contractures are overcome by first performing various hamstring release operations, pre- ferably with transplantation to the femoral condyles and then incising the fibrous and muscular retinacula on the medial and lateral surfaces of the joint, leaving the capsule and synovium intact. From 1937 to the author 88 records the treatment of 63 cases, seven hemipleglcs and 56 dipleglcs, with satisfactory results in four hemipleglcs and b-7 dipleglcs. HIPPS and WATERS (15) present case reports which clearly indicate the following specific "benefits that can he gained from the use of braces in cerebral palsy: Securing of muscle control is accelerated: elimination of many surgical procedures; correction of some deformities; and prevention of beginning deformities. ELLINGSEN (16) discusses the physiotherapeutic techniques in the five types of cerebral palsy considered to be treatable. While no new measures are advocated, the article forms a satisfactory compendum of existing modal- ities. ZAMUDIO and LETETTE (1?) of Mexico give the incidence of cerebral pal- sy as being 7 per 100,000 population and outline the Indications for physical and occupation therapy according to each of the five types. Myopathies Of the first group to be taken up are those considered to be congeni- tal. HIRSH et al (13) report that myotonia congenita is a hereditary condi- tion in which the patient is unable to relax his muscles quickly after a strong voluntary contraction as opposed to amyotonia congenita. Various authors report Increased excitability, increased myotonia on chilling, on administration of epinephrine and prostigmine, and relief of symptoms on ad- ministration of quinine. A six year old negro boy with the classical picture of myotonia congenita is presented. He had pronounced hypertrophy of many of his skeletal muscles, and an inability to relax antagonistic muscles rap- idly. Both the patient's mother and maternal grandmother suffered from the disease. Attempts at demonstrating a myotonia-Inducing substance in the blood had been unsuccessful* Curarization of this patient did not influence the myotonic pattern of response. Two cases of congenital myasthenia, occurring in a brother and sister are reported by LEVftN (19). In each case the disease process was seen clin- ically before birth as a delay in quickening. The one case, a male Infant, had involvement of the musculature supplied by the cranial nerves, particu- larly that of the eyes. He responded well to neostigmine when first seen at the age of four years. He died at the age of 10 years with pneumonia when neostigmine was withheld. The second case, young sister of the previous case, showed similar, less severe involvement, and she too responded to neo- stigmine therapy. Quinine sensitivity tests indicated the mother did not have latent myasthenia. Two of the mother's first cousins had bilateral con- genital ptosis. Congenital myasthenia as Illustrated by these cases differs from myasthenia gravis by its prenatal Inception and by its perfect symmetry in the pattern of muscular weakness. This disorder is also distinct from neonatal myasthenia, a severe but transitory myasthenic state occurring oc- casionally in children of myasthenic mothers. The first article under myasthenia gravis is one by STORTEBECEER (20) who suggests the possibility of an infective factor as its pathogenesis. The atrophy of some muscles, the round cell infiltration, the lymphocytosis and monocytosis, and the abnormally high antistaphylolysis tltre are cited in 89 strong support of the Infective factor. GrHOSSE-RORCKHOFP and WELTI? (21) are of the opinion that the appearance of myasthenic symptoms is probably caused by insufficient acetylcholine at the motor nerve ending. These fatigue symptoms occur in muscles not used when some substance, probably with a curare-like effect, has passed into the blood. The nature of these substances is discussed. They state that the symptoms disappear quickly without prostigmine. Myasthenia gravis, from an insurability point of view, is discussed by WEISMAN (22) where untreated myasthenia gravis may not cause death for many years, and it is usually characterized by spontaneous remissions which may last for one month or for 20 years. The therapeutic use of prostigmine had definitely lowered the mortality of the disease. Viets* mortality estimate of 10 per cent is probably as accurate as can bo obtained. THIBADDEAU (23) gives a description of a malignant myasthenia in a four and one-half year old child with death in six months from heart failure. He states that prostigmine had little effect and that the thymus showed lym- phoid inflammation. RITTBR and SPSTSTfl (24) interpret treatment and autopsy findings in a case of myasthenia gravis in a nine year old girl. In addition to thymecto- my, a variety of therapeutic materials, including prostigmlne, adrenal corti- cal extract and ACTH are reported to have "been tried without success. A hihliography is appended. KATZ et al (25) give an account of clinical remission in myasthenia gravis, induced by eight daily 25 milligram doses of adactar, a long-acting ACTH preparation. It is suggested that this patient met the state of ACTH lack Induced by ACTH withdrawal by producing a sustained Increase in adrenal cortical function. CLA03TT et al (26) describe the surgical technique of thymectomy for myasthenia gravis. They conclude that there is some connection between the thymus gland and myasthenia gravis since tumors of the thymus occur in 15 per cent of all cases of myasthenia gravis. The exact nature of the rela- tionship is unknown. It is recommended that thymectomy be advised in all Instances of thymic tumor if the condition warrants. (Ed: The authors are unable to show statistically that patients with myasthenia who have had thy- mectomy have benefitted materially from operation when compared with a group treated by medical means.) WEILL et al (2?) report that after a febrile Illness a girl of nine years developed a picture of myasthenia gravis with rapid aggravation. Den- ervation of the right carotid sinus was performed, but six hours later the child showed agitation and rapid pulse, lowering of the arterial pressure and frothing at the mouth. Despite prostigmine and stimulants the child died after 24 hours. Autopsy revealed only slight hyperplasia of the thymus, without tumor. The cause of death is discussed — a reflex mechanism being considered probable. Operative attack on the thymus in myasthenia gravis is discussed by PEYSER (28) and a plea is made for surgery in cases with respiratory dlffl- 90 ciilty. A ten month follow-up on a case of myasthenia with complete remission following removal of malignant thymoma is given. A case of myasthenia gravis associated with undetected thymic retlcu- loendithelioma is described hy DE 7EDAS (29). During the two year course, patient is said to have developed eye signs with subjective vague colored scotoma, supposedly produced by alterations in the refractive index of the visual media by prostigmlne. RIDER and McDONALD (30) present one case of myasthenia gravis resistant to prostigmlne therapy and associated with a malignant tumor of the thymus gland. A review of the literature citing previous instances of a thymoma in other cases of myasthenia gravis are listed. The writers feel that the pos- sibility of a malignant thymoma should be considered in every case of myas- thenia gravis. WEISMAN (31) reports a case of myasthenia gravis in which the patient complained of weakness and fatigue. Decidedly increased weakness occurred following administration of qulnidine. Response to treatment with neostig- mine was prompt and dramatic and was accompanied by almost complete cessation of palpitation. Atrophies and dystrophies; JACOBS and CARR (32) in the largest series of progressive muscular atrophy of the peroneal type thus far reported, dis- cuss the orthopedic management and end results. They report on 80 cases, 45 treated surgically with a five year or longer follow-up on 25. References to historical data, hereditary factors, signs and symptoms are made, together with an extensive bibliography. Surgical management consists of plantar fas- ciotoray and/or lengthening of the tendo achllles as Indicated,then foot sta- bilization of the nHoke” type, followed by section or anterior transplanta- tion of the posterior tibial tendon or of the anterior tibial tendon as de- termined by existing strength. The results are encouraging. TANSELL (33) describes two classical examples of progressive muscular atrophy of the type described by Charcot and Marie. He mentions that some authors have attributed this progressive muscular atrophy to luetic infection, but in his cases, be has eliminated this possibility from the etiological fac- tors. The details of diagnosis are enumerated in great detail. CRITCHLEY (3*0 gives the history and classification of the muscular dystrophies. There is a constant Involvement of muscles of the following three classes; those muscles which develop early in the fetus; those muscles which are regressive; those muscles essentially associated with the function of fixation or the maintenance of posture. PBRKOFP and TYLER (35) investigate muscular dystrophy as to the signi- ficance of myobilin in stool pigments. The substance "myobllin,” described by Meldolesi, is present in stools of normal patients, and no significance can be attached to this finding in muscular dystrophy. BO YES et al (36) demonstrate the pedigree of hereditary progressive muscular dystrophy. The disease has been transmitted through three genera- tions, A single dominant mode of inheritance seems to be indicated in this pedigree; however, since the only married male patient who produced sons 91 did not transmit the disease to them, a dominant sexllnked type of transmis- sion (as previously reported hy Bell) cannot he excluded. MAYERHOPER (37) reports improved function in cases of progressive mus- cular dystrophy with the systemic administration of small to medium doses of insulin. He finds it especially advantageous in more recent cases in whom advanced muscular wasting and pseudo-hypertrophy is not yet present. He at- tributes the cause of this functional improvement to the increased formation, better storage, and improved consumption of glycogen in the diseased muscle itself. MBURER (38i39) interprets the results of treatment of muscular dystro- phy with resection of the carotid sinus nerves. Appreciable Improvement was seen in 17 cases. Treatment of progressive muscular dystrophy is outlined by MAYERHDFRR and GRUNER (40). SIMIGE and HASRTOG (4l) relate the case history and autopsy findings on a 41 year old man who had developed dystrophia myotonica at 17* The find- ings were as follows: total alopecia, facial and soft palate paralysis, at- rophy of the sternocleidlomastoid muscles and of the muscles of the hands, great difficulty in opening the fist, myotonic contractions of the hand mus- cles and of the tongue, absence of the Achilles tendon reflex, testicular atrophy, absence of libido, apathy. The autopsy findings are described. Reference is made to the cases of dystrophia musculorum progressiva following poliomyelitis which are described, in the literature. KEIZER (42) and COPELLO (43) each report a case of muscle dystrophy. BOECKER (44) offers x-ray pictures of the gastrocnemius in a case of juvenile form of progressive muscular dystrophy in which the muscle fibers were penetrated by a fish bone like pattern. The etiology and pathogenesis of the diseases are discussed. The miscellaneous articles Include one by BINGHAM (45) who presents 59 cases of muscular fibrodystrophy of children. The symptoms consist of easy fatiguabillty and muscular cramps in the back and lege. There is poor posture, and there may be scoliosis, pes cavue and contracted toes. There is usually a history suggestive of a mild attack of poliomyelitis. There is no true muscular weakness, but rather firm contracted muscles. Neurolo- gical examination is negative except for depressed deep tendon reflexes. Treatment is usually successful and is conservative consisting of hot packs, stretching and manipulation. The author suggests that this disorder probably represents cases of mild untreated or unrecognized, poliomyelitis, (Ed: Confirmation of this entity is lacking as are the pathogenetic implications.) Scapulo-humeral myopathy is discussed by EUZIER1? et al (46), HYLAND (47) discusses the syndrome of periodic paralysis which includes intermittent attacks of flaccid paralysis of the trunk and extremities, usu- ally coming on during sleep, with diminution or absence of tendon reflexes and impairment of electrical excitability of muscle and nerves. Conscious- ness is retained throughout. In a large percentage of cases, there is hered- 92 itary and familial Incidence of the condition, hut at least 20 per cent of the cases occur sporadically* Attacks of paralysis in susceptible indivi- duals usually come on when the level of potassium in the serum is 12 milli- grams per cent or less. Potassium levels of this degree do not affect norm- al Individuals. Administration of adequate amounts of potassium salts brings about rapid recovery from paralysis in susceptible individuals. The etiol- ogy of the condition is thought to be Innate metabolic or neurogenic defect. The observations on a sporadic case are reported. WISWELL et al describe the Sturge-Weber syndrome as consisting of a combination of a facial vascular nevus, intracerebral calcification, convulsions, ocular abnormalities, and mental retardation. A case Is re- ported. Authors MILLER and MILLER (h>9) discuss the group of conditions termed post-traumatic reflex dystrophies. The syndrome is common, follows injury and presents pain, vasomotor changes and altered motor function. The syn- drome usually responds to early treatment of sympathetic blocking drugs or local sympathetic blocks before flbrotic and trophic changes take place. (Ed: Severe irreversible dystrophies may require pregaglionlc sympathectomy in the cervical area. Unfortunately no proven means of case differentiation exists as yet.) A syndrome complex comprising numerous visceral, somatic and emotional disturbances is described by GAYRAL (50). In general, a physical basis for a class of vague, bizarre and often baffling symptoms is given. The primary patterns consist of attacks of facial, cranial and cervical pain, pseudo- vertigo, laryngeal and pharyngeal paresthesias and spasm, anxiety, facial vasomotor instability, neck tenderness and spasm. There is general psychic instability in these patients. It is felt that the cervical sympathetic system with its intracranial anastomoses produces this complexity, often secondary to cervical trauma or arthritis. Less freouent are attacks of general visceral dysfunction; bizzare somatic sensations; or patterns of thought fogging, chilled perception, asthenia, retinal hypotension and my- driasis. The use of paravertebral cervical blocks, treatment of arthritis, demineralization, and sublux&tion in the care of these cases is discussed. GUILD (51) studies the effects of decamethonium iodide in muscular hy- pertonus in seven cases. In two cases, improvement in performance, although significant was not dramatic, and beneficial results were transitory. Un- pleasant side effects largely offset the advantage of better performance. SCHACT1R (52) summarizes the findings in general paresis of children, including occurrence of tabes and convulsive crises. He concludes that mod- ern antibiotics may modify the usual poor prognosis. Amyotrophic lateral sclerosis and its differential diagnosis is des- cribed by FRIIDMAN and FRETOMAN (53)* In their article they point out that it is characterized by upper and lower motor neuron pathology. It occurs most often in middle life and is progressive in the majority of cases. This paper presents a study of 111 cases. An extensive review of the literature is presented. On examination, uniform wasting of the hand muscles, wide- spread fibrillations, and increased deep reflexes in all extremities are prominent features of this disorder. The average length of the disease is 93 given as 25 months and it uniformly culminates in death. The differential diagnosis is a problem of distinguishing conditions which involve the cord and the hulh and have the clinical features of an amyotrophy, spasticity, bulbar impairment or certain combinations of these. The treatment of the disease has, so far, consisted of vitamin E (tocopherol), and more recently, cytochrone C. ALAJOUANINE et al (5*0 detail a case history in a 50 year old male with amyotrophy initially in the upper limbs and neck and extending to the lower limbs. Anatomical examination showed the lesion to be exclusively spinal and degenerative in the ventral columns only. The authors, LEHOCZKY and ESZENYI-HALASY (55)» state that the exact differences between chronic anterior poliomyelitis and Aran-Duchenne disease are difficult to define. On the basis of clinical study they propose a more satisfactory neurological term as “Progressive Amyotrophical lateral Sclero- sis of the Chronic Poliomyelitis Type." They Justify this on the manlfestion of degeneration of the nerve cells of the spinal cord without histologic evi- dence of chronic or subacute inflammation. Nervous System Disease of Various Causes Multiple sclerosis: FSLBER (56) considers geographic factors in the spread of multiple sclerosis. This disease is appreciably more common in Northern than in Southern Switzerland. Similar variations are observed in Germany, except that the disease is more common in the Western area where the population Is of teutonic descent. In Europe, as a whole, the disease is more common in the North than in the Mediterranlan area. The incidence is very high in Great Britain and Ireland, and statistics show that the in- cidence is higher in Northern Europe (especially Scandanavla, Finland and England) than in the United States. LIMBURG (57) makes a statistical survey of multiple sclerosis as to geographic distribution, mortality, seasonal variation, sex, race, age at onset, and duration of illness. There does not appear to be any selective association between multiple sclerosis and sex, race, occupation or popula- tion density. Incidence does vary with the mean annual temperature. The colder the climate, the higher the death rate. The duration appears to be much longer than generally supposed, e.g. in the United States the median duration for a fatal case is about 27 years. A general discussion of multiple sclerosis is given by SCHUMACHER (58)* This paper presents a lengthy bibliography to support detailed discussion. The effectiveness of drug therapy in the disease is discussed and it is the author's opinion that at the present time there are no drugs which effective- ly control the disease. SCIARRA and CARTER (59) report that the duration of life for 20 to 30 years is not unusual but that survival for longer than 30 years is rare. Three cases of multiple sclerosis are presented in which the patients sur- vived 30 years, 31 years, and years, respectively, after onset of illness. MACKAY (60) makes a comprehensive study of the literature and finds that the Instances of familial multiple sclerosis to date number 70, with an 94 aggregate of 177 persons. To these, he added fire Instances, Including 11 persons. The author offers the following theories as consistent with the present Information; (a) there Is a familial, constitutional or vulnerabil- ity, to multiple sclerosis, and (h) there Is a second, nonfamlllal, possibly exogenous cause which is competent to evoke the disease, especially when the first, or constitutional, factor is already present. An extensive bibliog- raphy is appended to this article. ABHAHAMSOH (6l) discusses 42 cases of disseminated sclerosis. He dis- cusses in detail the possible pathogenesis and postulated the possibility of a cyclic Immunity-sensitivity response to the tubercle toxin as being a pos- sible explanation for the remissions and exacerbations seen in this disease. ADAMS et al (62) describe the symptoms and signs of 389 cases of dis- seminated sclerosis. Weakness in one or more limbs was the first symptom in more than half the cases examined, while the visual upset was the earliest manifestation in an additional 26 per cent of the patients. The onset of the disease is found generally to occur in the age group 20 to 45 years, and, when disseminated sclerosis is suspected in patients outside these limits, other etiological factors should be carefully considered. Stress is laid on the need of recognition of the disease before permanent damage has been in- flicted on the central nervous system. Whatever advances in treatment the future may hold, the degree of recovery will depend upon the stage at which a diagnosis is first established. The author appends a bibliography. In a severe case of multiple sclerosis PRICK and CADOH (63) report an experimental psychological test to gain insight into the processes of deter- ioration of personality. The IQ decreased from 94 to 34. Qualitative anal- ysis shows that mechanical memory is most heavily damaged. A case of multiple sclerosis is reported by SAHS et al (64), It is that of a 53 year old male who expired suddenly after a brief cardiorespir- atory attack. In an article on pregnancy and multiple sclerosis, MARTHLLI (65) pre- sents statistics from 100 cases of multiple sclerosis followed since 1943 to date. Of these, 40 are men and 60 are women. Of the latter, 22 have had no pregnancy. In four women, exacerbation of the disease is seen in preg- nancy with the first manifestations in the first trimester and the disease complete (or full-blown) towards the end of pregnancy. In two cases, in the active stages of the disease, spontaneous abortion is reported in the second and third months. In six cases, the disease is said to have developed after pregnancy. The author mentions the necessity of having to advise those who are afflicted with the disease and also the family the risk of pregnancy. Research and statistics on multiple sclerosis includes a study of the crystalline albumin, gamma globulin and total protein in the cerebrospinal fluid of 100 cases of multiple sclerosis and in other diseases by RABAT et al (66). The cerebrospinal fluid albumin and gamma globulin have been studied in 100 cases of multiple sclerosis, 85 per cent are found to show an increase in gamma globulin. Values for the cerebrospinal fluid albumin are generally normal. The increase in gamma globulin is not specific for multiple sclerosis, since similar findings are obtained in neurosyphllls and in certain other diseases. A bibliography is appended. 95 A group of 23 cases with a diagnosis of multiple sclerosis is studied by HESS (6?) with emphasis on gastric functions. In all 23 cases, hyperaci- dity and hypermotlllty of the stomach is demonstrated. Three case histories are presented of patients having multiple sclerosis with marked gastric dis- orders. The pathogenesis of the hyperacidity and the hypermotlllty of the stomach is discussed in its relation to the lesions in the region of the hy- pothalamus. Biometric-statistical data on the characteristics of arterial tension in multiple sclerosis are listed hy ROGER and SCHACTER (68). TIMME (69) discusses the concepts of functions of the spinal cord since the third century. He gives the symptomatology of multiple sclerosis as determined hy the Commission of the Research Association in Nervous and Mental Disease in 1921. Re ponders the pertinent question; Is the patho- logical process of multiple sclerosis of inflammatory or degenerative nature? Under paralysis agltans EKBAUM (70) states that it is generally held that the reflexes in Parkinson’s syndrome are fairly often brisk and variable but not abnormally exaggerated. A variation in reflex response is intermit- tently associated with trauma, and it concluded that the intensity of the re- flex responses depends on the phase of the trauma when the stimulus is ap- plied. PALMER and GALLAGHER (71) analyze 16 cases of Parkinsonism treated with phenothiazine hydrochloride. It is "believed to he capable of affecting beneficially any symptom or complex of symptoms from which the Parkinsonian patient is suffering, notably his mentality. The findings in the 16 patients are as follows: Complete alleviation - one; good result - ten; improved - no change - one. The dosage used is four to ten tablets (50 milligrams) per day. The general toxic events of the drug are listed as follows: (a) drow- siness and lassitude with or without vertigo appearing half an hour after dosage, lasting to two hours and being most apparent in early treatment; (b) dryness of the mouth, transient diplopia, vasomotor reactions which are rarely found and disappear spontaneously. They feel it may be confidently recommended as a valuable remedy in a treatment of this condition. Classical treatment, chiefly with Belladonna derivatives, is described by PECKER (72). The modern pharmacopoeia according to him Includes synthet- ic anticholinergic and adrenergic compounds. A list of drugs is given. Synthetic curarizing drugs are being tried. Radiotherapy has been found ef- ficacious in 60 per cent of the postencephalitic cases. Certain mental dis- turbances (agitation with perversity) may be Indications for topectomy. Articular stiffness response to hot baths and massage with active and passive mobilization, and the cooperation of the patient and relatives, eta remain essential factors for success. TOSS (73) reports 18 cases of Parkinson's disease treated with Benadryl (200 milllgrams/2h hours). Objective Improvement is cited in two cases. Ben- adryl may be of value in cases which do not respond to the usual drug therapy. In six cases of Parkinsonism treated with Dlparcol, PALMER and BLACK (7*0 report that two had significant responses, but one of them died from pneumonia. It appears that some cases of this disease will be benefitted, 96 tut there is danger of reaction, l.e. conjunctivitis, giddiness, and somno- lence, depression of cough reflex. (Ed: The results are inconclusive.) The effectiveness of modern drugs in the treatment of Parkinsonism and similar diseases Is debated by TJIBERALL and JORDAN (75)• They describe a series of cases treated with sympathetic antispasmodlcs. Their series com- prised 52 cases. They report favorable response in from one-third to one- half of the total number. The percentage of improvements noted is not felt by the authors to be higher than that obtained from the previously used sol- cnaceous plants. REMOUCHAMPS and VERBEKE (76) recount personal experience with artane in the treatment of Parkinsonism, They find it superior as an antispasmodlc to atropine and other previously employed remedies, confirming the observa- tion of American authors. MAROGER (77) discusses the therapy of Parkinsonism in Bulgaria. He stresses the need for Vitamin C, a vegetarian diet, elimination of nicotine, alcohol, and caffeln. His rehabilitation program Includes medication, mus- cle training, correction of deformities, occupational therapy and psychother apy. Two cases of Gulllain-Barre syndrome, polyradiculities, in Infants, are reported by GLAUBER (78). The first case occurred following pyodermla and the second started one week after a smallpox vaccination. Both cases recovered completely. The pathogenesis of a possible neuroallerglc reaction and the differential diagnosis are discussed. KLOVSTAB (79) reports a case of mononucleosis in a six year old boy with acute polyradiculitis of Guillaln-Barre as well as otitis, lymph node enlargement, cardiac symptoms and ischiopublc osteochondritis. The author points out the possibility that the entire condition may be due to hypothet- ical virus of infectious mononucleosis. CACCIAPDOTI (80) discusses the role of vasospasm in the production of CHS lesions in polio and describes a method of vaso dilation with oral digi- talis and intramuscular acetyl choline. He states that many patients have shown significant regression of paralysis from this therapy during the acute stage of the disease. Traumatic Infections and Toxic Lesions Four articles are Included under general. In the first, EAMMFS (81) discusses trauma to the nervous system. He states that the history of the development of our knowledge of this subject parallels very closely the his- tory of the war. During and following each conflict, the mass of clinical material, concentrated into centers in a way that never can he done in peace time accounts for the more rapid evolution of knowledge. He lists three outstanding contributions of the second World War to the subject of nervous system trauma. The first is factual knowledge in neurophysiology and new antibiotic agents which made possible new surgical techniques. The second is a realization that our responsibility to the patient continues through rehabilitation. The third contribution is the development in large centers of coordinated teamwork. 97 On technlone of peripheral nerve surgery SPURLING- (82) states that fre- quently nerve lesions are overlooked, even by physicians who are highly trained in the management of trauma* The technique of evaluating the integ- rity of the main nerve trunks of the upper and lower extremities by studying the movements of the thumb and great toe is described* It is recommended that all operations upon peripheral nerves be at least started under local anesthesia since ouch valuable information can be obtained by electrical stimulation of the exposed nerve trunks at operation. The contraindications to primary nerve repair in an injured extremity are outlined. The author favors delay of the nerve suture for 15 to 20 days after severance of the nerve, at which time the eplneurlum first attains the tensile strength which facilitates nerve suture* The alteration which occurs in the distal nerve segment following nerve severance is described. Analysis of data from 8000 cases of nerve suture listed in the Army’s Peripheral Nerve Register indi- cates that in 85 per cent of cases there is unmistakable evidence of regen- eration. The author observes that in nerves which supply muscles concerned with gross movement, functional recovery is more perfect than in nerves sup- plying muscles concerned with non-precision movement. MERLE D’AUBIGNE (83) compiles the results in a series of 82 patients treated for residual paralysis of the upper limb. He discusses the general rules to be borne in mind in choosing between arthrodesis and muscle trans- plantation. HENDRY (8*0 believes that it is impossible to classify the flail upper limb because of the variation of the paralyses in location and degree, and deformity. Two factors must be considered in every case? the physical con- ditions present in the limbs; and the general attributes of the patient. He discusses various surgical procedures for the flail limb and feels that re- tention is preferable to amputation. Peripheral nerve paralysis occurring postoperatively in five cases is reported hy EWING (85)* Although upper arm paralysis as a sequel to surgery offers an excellent prognosis, it is distressing to both patient and surgeon, and it is preventable* The cause is thought to he stretching of the plexus over the humeral head when the extended extremity is abducted to 90° to facil- itate venoclysis, etc* It is aggravated by pressure of the shoulder rest if the patient is tilted into the Trendelenberg position and more so if curare is administered, due to loss of tone in the trapesrlus. He stresses the im- portance of prevention. KIIOH (86) hypothecates that brachial plexus Injury complicating surg- ery is probably due to traction-compression injury, secondary to abduction of the extremity, in combination with the Trendelenberg position and the use of muscle relaxant agents. Prophylaxis is assured by maintaining the arms adducted and the elbows flexed. PAIMAR (8?) describes a dynamic splint for the wrist and fingers for radial nerve palsy. The splint is constructed of plexlglas. Rubber bands are incorporated into the splint to give the flexors a certain amount of re- sistance for normal action. SOUTITZJTY (88) states that the most common etiological factors in ra- dial nerve injuries are: pressure, fractures, dislocations, wounds, tumors, 98 and peripheral neuritis. A rather complete discussion of functions and find- ings is given. HUDSON et al (89) report 20 cases of unilateral sciatic paralysis in the newborn, sometimes accompanied hy cutaneous gangrene. Accidental injec- tion of cycllton into an artery instead of a vein in the umbilical cords is suggested as a possible cause of the lesions. Experimental proof is as yet lacking, but the evidence in favor of this theory is as follows: (a) the cases are reported only in the hospitals in the city of Liverpool in which cycliton was in use, (b) the only common factors were asphyxia at birth and the injection of cycliton into a cord vessel, (c) the lesions are consistent with the results of ischemia due to disturbance of blood flow in the internal iliac artery, and they are comparable to the lesions produced by intra-arter- ial injection of thiopentyne, and (d) no further lesions have occurred since the cycliton has ceased. (Cycliton is not now sold in England, although it is used extensively on the continent and in other points of the world.) CHAVANT and HAOSHMULLER (90) present a case of sciatic paralysis from a bullet wound in the popliteal fossa 23 years before. It began with an attack of neuritis. Involuntary painful, torn muscular contractions, local tenderness and progressive muscular calf hypertrophy. He discusses the pos- sible pathogenesis. SOHIER (91) presents a case of auto grafting of the sciatic nerve fol- lowing a war wound, with improvement of the associated syndrome of causaIgic pain. MERLE (92) discusses two clinical findings in an attempt to distinguish L5 from SI nerve root Involvement. A "list” was found more commonly with the former and also sciatic paralysis was more frequent with L5 involvement. In- volvement of the external popliteal nerve alone invariably indicated fifth root involvement. DUE5IN (93) summarizes the typical history and findings in cases of low hack pain associated with sciatica* He stresses the conservative element of therapy even when a ruptured intervertebral disc is suspected and mentions the surgical indications and feels that a combined laminectomy and soinal fusion is the procedure of choice. TALBOJ (9*0 states that the Taupet and Lambrlnudl operations give the most satisfactory functional results in paralysis of the external popliteal branch of the sciatic nerve. SCHWENSEN (95) describes a case in which he attributed a transient per- oneal palsy to penicillin therapy of a lung abscess, A clinical report is given of one patient with multiple cranial and peripheral tlbial nerve with a satisfactory functional result following secondary suture, excision of the neuroma, and flexion of the knee. Complete function recovery in approximate- ly 20 months is reported • DBfTISART (96) contributes a case report of section of the anterior tlb- ial nerve with a satisfactory functions! result following secondary suture, excision of the neuroma, flexion of the knee. Complete function recovery in approximately 20 months is reported. 99 Under articles pertaining to spinal cord. BAITKR (97) advocates measures to educate the public as to means of preventing injury of the spinal cord. A brief summary of the treatment of injuries of the cervical thoracic and lumbar regions by skull traction, laminectomy, spinal fusion, and braces is given. LWIN (98) relates that breach presentations developed lower mo- tor neuron palsy of both legs following a difficult labor and delivery. He states that spinal tap showed a complete block and a permanent reaction of degeneration appeared in the legs. Muscle tonus following injury of the spinal cord is described by BBCKJ5R (99)* He states that the restoration of muscle tonus follows different pat- terns after complete transection of the spinal cord, that after transection the pattern is characterized by summation of synergic reflexes, while after pyramidal lesions it is of the spastic type. The author calls the transec- tion syndrome "kinetic pyramidal" while he considers the pyramidal syndrome as being "static pyramidal." Early occurrence of the kinetic type is usu- ally followed by a poor restitution of nerve function. The author feels that the kinetic syndrome is influenced greatly by the vegetative nervous system, as shown by the influence of nicotinic acid ephedrine, anxiety, rage, and its absence during sleep. He interprets the syndrome as being an adapt- ation syndrome. SUNG (100) considers the present surgical treatment of spinal cord in- juries unsatisfactory in that insufficient cord is exposed at laminectomy. He considers early intervention imperative to reverse the posttraumatlc changes in the spinal cord and states that these changes are mainly due to vascular occlusion and therefore reversible. COLLING and ROSSITBR (101) state that cerebrospinal fluid contains cholinesterase and pseudocholinesterase. Occasionally, there is a signifi- cant rise in the true cholinesterase with syphilis, which Is not correlated with either the cerebrospinal fluid, Vasserman or reaction of protein. There is an increase of the pseudocholinesterase in the cerebrospinal fluid with meningitis, and occasionally with poliomyelitis, which is correlated to a lessor degree with the protein. The authors postulate that the true cholinesterase might be derived from the brain or spinal cord and the pseu- docholinesterase from the plaama. In any case, the determination of the true and pseudocholinesterase activity of the cerebrospinal fluid is of lit- tle diagnostic slgnlficance. The concept of myelopathy, writes LBHOCZKY (102) applies to a disease of the spinal cord in which the typical histological features of inflamma- tion are entirely absent, and the disease is considered to be due to infec- tive, vascular, or mechanical factors. Thus, myelopathy is a degenerative affectation of the cord. The mechanical form of myelopathy is not dealt with in his article. The author has observed 160 cases of myelopathy among cases (2.13 per cent) in eight years. The following differential diag- nostic points are given: (a) an acute onset is common, (b) Crouzon!s sign (Babinski plus Oppenhelm) is not pathognomonic for myelopathy but merely shows the presence of lesione of the dorsal and lateral columns, (c) the cerebrospinal fluid and blood are usually normal, (d) the greatest difficulty is the clinical distinction of myelopathy from multiple sclerosis. The et- 100 iological factors include syphilis, chronic alcoholism, secondary anemia, influenza, furunculosis, inanition, diarrhea with colitis, chronic pyemia, immunization against typhoid fever, encephalitis, and nicotine poisoning, For treatment, adenosine triphosphate, vitamin Bl, and nicotinic acid, alone or in combination, are recommended. BASTAGLI (103) tells of two cases of acute transient myelitis involv- ing the posterior tracts and anterior horn areas respectively. Cerebrospin- al fluid findings were normal and there were few sequelae. An account is given by UNG-LEY (1C&) of attempts to determine the nature of the agent in liver effective in subacute combined degeneration. Eight pa- tients with subacute combined degeneration were studied by a quantitative method with vitamin Two were slightly, four moderately, and two severe- ly affected. The duration of the difficulty in walking ranged from two months to 11 years. Four of the eight cases exceeded the expected rate of improvement, two attained it, and two fell just short of it. Vitamin therefore, as effective as liver extract not only in pernicious anemia but in subacute combined degeneration. The existence of a separate neuropoletlc factor need no longer be postulated. Except for patients who have become sensitized to some impurity in the liver fractions, the pure substance has no advantage over the commercial liver extracts. STECKLSMACHER (105) records the death of a woman suffering from Slm- mond*s cachexia with spastic paraparesis and hyperalgosic symptoms of hoth legs. All signs of an adrenal crisis with delirium, excitement, and syncope are cited and autopsy revealed an inflammatory process of the pituitary gland, while the adrenals showed a perfectly normal structure. The spinal cord showed severe changes even to the naked eye, consisting in heterotopia of the dorsal portion on cross sections. Microscopically, scattered patches of degenerative destruction in various tracts were seen, reaching from the lumbar up to the cervical portion, without any inflammatory reaction and with intact blood vessels. The relation between the pituitary and degener- ation of the cord is discussed. BIKDB (106) reports the treatment of postdiphtherltlc paralysis with intrathecal injection of 0,5 milliliters of formal toxoid. Serious reactions in the form of meningitic signs appeared, but there was a remission of the paralysis with recovery from the secondary meningitis. KISSEL and AMOULD (10?) report a case of syringomyelia in which the trophic polyarthropathy preceded the disturbance of the thermal sensation by 22 years, A localization of the lesion in the medullary synaptic area was considered possible. BAZZI (108) presents a series of cases of syringomyelia in 6000 neurological cases. The author comments that the cervical form was encount- ered in approximately 68 per cent of the cases, the dorsal form in 9 per cent, the lower form in 23 per cent. According to his findings, the lower form cannot be classified "exceptional” as some of the French authors have reported. The author did not encounter in his cases the findings frequently described in syringomyelia (hyperdactylia, syndactylia). PALSY and WHITE (109) discuss diagnosis and specific therapy of lnflt>- 101 enzal meningitis. Severe cases have less than 15 milligrams per cent cere- brospinal fluid sugar and are treated with combined streptomycin and sulfa- diazine. Streptomycin should be given intrathecally as well as parenterally and in large doses. HAZEIRIGG and HAVEN (110) evaluate the Queckenstedt test. Cerebrospin- al fluid proteins and pantopaque myelography are used in cases of spinal cord tumors whose diagnoses are uncertain. Four cases arc cited in which intra or extra dural tumors were initially confused with degenerative cord condi- tions or functional states; diagnoses of surgical lesions were made by abnor- mal raanometric response, elevated proteins and filling defects seen at mye- lography, The author states that all cases were successfully operated upon. THOMPSON and RICE (111) report four cases of secondary amyloidosis in spinal cord injuries found at autopsy and discuss the clinical significance of this process. Spinal cord injury is accompanied by the following triad of inflammatory processes: decubitus ulcers, chronic osteomyelitis, and ur- inary infections along with a profound disturbance of metabolism. Amyloid degeneration is a distinct possibility but is not common. Clinical diagnosis is difficult. The elimination of infection can be a factor in the prevention of amyloidosis. The use of whole liver may help in therapy. A clinical syndrome of nutritional origin, well-known in Singapore and consisting of lesions of the skin, mucous membranes, and nervous system is described in a case presented by DANARAJ (112). The literature is reviewed. Some of the neurological findings recorded are: burning feet, muscular weak- ness, ataxia, paresthesia, and loss of visual and auditory acuity none of which fit into the clinical picture of beri-beri or subacute combined degen- eration with only a superficial resemblance to tabes dorsalis. The author reports that the patient seen in the Singapore General Hospital responded rapidly to a liberal diet supplemented by milk and eggs and a course of ni- cotinic acid and riboflavin. Under complications SOULE and STIFF (113) describe changes in bones and soft tissue. In a series of 63 patients with spinal cord or caudal les- ions, soft tissue calcifications were noted in 2h, These lesions occurred about the hips and knees which is a bad sign and indicated poor prognosis. Only three of the Zk cases showed any clinical improvement. No criteria could be established at the time of writing as to which type of patients would develop ossifications. The pathomechanics of this phenomena is un- known. MEIROWSKY and SCHEIBERT (11*0 report observations made on three pa- tients with traumatic myelopathy and a segmentally innervated bladder. Bi- lateral sacral neurotomy of S3, Sh and S5 was performed. The patients main- tained a relaxed automatic bladder, became able to have sexual intercourse, and there was some improvement in rectal incontinence and sensation. Paraplegia is dealt with by DANE (115)* He reports that of ten para- plegics (apparently of World War I) who came under his care, eight died within the first three years. The remaining two, despite section of the thoracic cord, remained in good general health after 32 and 33 years res- pectively, The author believes that modern treatment will Increase the per- centage and length of survival of paraplegics. 102 In the treatment of spinal paraplegia GUTTMAN (116) "believes in phys- iotherapy and gives a detailed discussion of his "beliefs* The latter half of the article is utilized in the discussion of the readjustment of normal parts "by compensatory training, employing muscle exercises, "braces and sup- ports* In consideration of the "brain, an article on neuropathy is presented "by IRONSIDE (117)• One year duration of partial third nerve and complete sixth nerve palsy on left side, followed "by sadden development of left foot drop is reported* THOMAS et al (118) state that it has not "been disproved that pallidum type rigidity cannot develop without involvement of the pyramidal tract* The author continues that it is difficult to establish in a great number of pathological cases whether there is a pyramidal contracture or pallidal ri- gidity* He contends that by studying the symptoms more and more thoroughly, there will be opportunity to determine the part olayed by the cerebellum, ("roll's column and other centers that have been suggested as causes for Strumpell's disease (Polloencephalomyelitis). BICNERSTAFP (119) presents 18 cases of familial spastic paraplegia. He discusses the signs and symptoms which give evidence of overlap with amy- otrophic lateral sclerosis and cerebral diplegia. The possible genetic re- lationships between the ataxias, myopathies, hereditary spastic paraplegia, and other congenital anomalies are mentioned* GARLAND and ASTLEY (120) describe a family showing a syndrome of spas- tic paraplegia with the unusual features of amyotrophy and marked pes cavus. He discusses this disease and notes the invariable excellent prognosis* Articles on hemiplegia include one by SCHWAHTZMAH (121) who reports a case of transient hemiplegia, associated with febrile convulsions. He says that accompanying or subsequent to convulsions of febrile origin, almost anything can be encountered from irritability to coma to paralysis. The most likely explanation was thought to be due to areas of focal edema and hyperemia of the brain which accompanied the convulsion. BARTJE and YOUCHNOYETZKI (122) cite a case of hemiplegia in a child following tonsillectomy. 2WSIGHAPT (123) reports a case of hemiplegia following tonsillectomy. The literature is reviewed, the role of the carotid sinus noted, and the possibility of causing brain damage by elevating and lowering the blood pressure is suggested* The use of oxygen rather than air to bring ether to the patient is advocated. Anesthesia for tonsillectomy should not be rele- gated to occasional anesthetists* CHTJSED.et al (I2h) report two cases of hemiplegia following 35 per cent diadrast cerebral angiography with treatment by etomon chloride and subsequent recovery. MAU (125) feels that, in certain cases of spastic pes cavus deformity, the Stoeffel operation does not correct fully or maintain correction of this deformity. He therefore advocates transplantation of the gastrocnemius 103 •rigin to the proximal tibia (Silverskjold’i operation) in conjunction with the Stoeffel procedure, before considering achlllotomy, He discusses the indications for this operation together with the operative technique and postoperative management, and he lists the results of eight cases so treated. C07ALT et al (126) utilize known facts of muscle physiology in the re- habilitation of spastic palsy of the upper extremity. These include the un- usual power of elbow extension when the face is turned to the affected limb, and the fact that deltoid power is at maximum when the arm is at shoulder level. Their occupational therapy tasks are begun with the am supported and then this support is gradually withdrawn. Principles of progressive re- sistance exercises are shown. According to NWMAN and COHEN (12?) the outlook on hemiplegia is not gloomy. The management of the stages of hemiplegia is outlined. Methods of evaluation are described. Including the consideration of neurologic, psychi- atric, medical, social, and vocational aspects. The authors think the chron- ic, semi-disabled hemiplegic patient can be restored to a semblance of norm- ality. BARUE and MENACED (128) report four observations in which mild mental derangements were associated with Pagets Disease of bone. Pain Under general discussion of pain is included an article by HA7ERPIELD and KESDY (129), They report that constant pain produces slowly progressive personality degeneration which often leads to barbiturate habituation and narcotic addiction# Neurosurgical procedures designed to alleviate the suf- fering of patients with intractable pain may be divided into two groups: (a) those that interrupt the nerve nathway for pain and (b) those that in- terrupt nerve pathways that modify the patient’s reaction pattern to pain# The first group has been classified under three headings: (a) interruption of nerves distal to their ganglia, (b) interruption of the sensory roots of nerves, and (c) section of the pain tracts in the spinal cord or brain# There are few Indications for interruption of nerves distal to their ganglia because of loss of motor as well as sensory function. It may be indicated In cases with amputation stump neuromas, recurrent scarring about a nerve, or gangrenous extremities awaiting amputation# The interruption of sensory roots of spinal nerves, the posterior rhizotomy, produces loss of all modal- ities over the dermatome of that particular nerve root, but it does not af- fect motor power# It is Ideally suited for localized pain in the trunk, less suitable for upper extremities, and rarely indicated in lower extremity pain# Spinothalamic tractotomy produces loss of sensation for pain and tem- perature on the opposite side of the body below the level of section# It is not the procedure of choice for pain above the nipple line# Bilateral pre- frontal lobotomy is advocated for the patient with diffuse pain or for the patient whose pain is likely to spread# PAILLAS et al (130) discuss prefrontal leukotomy and topectomy in the treatment of intractable pain. Many authors discuss sympathectomy and an article entitled "Surgery of the Sympathetic Nervous System" by MacCARTY (131) presents views as to 104 the explanation for the existence of so-called sudomotor "escape* areas on the body surface following thoracolumbar sympathectomy. The "escape" areas are irregularly-shaped areas of Increased sweating usually found on the low- er abdomen and anterior thighs persisting for several weeks after operation. These correspond to the dermatome segments of T12 to L3. It is suggested that intermediate ganglia together with their associated preganglionic con- nections and postganglionic fibers afford the anatomical explanation for the retention of sweating in the "escape" belt. EVANS (132) gives his views on the selection of patients for sympa- thectomy. The more vasospasm that can be indicated as the cause of symptoms of the "picture," the better is the response to sympathectomy. The author feels that operation in upper extremity Raynaud's disease is not good, but he states that sympathectomy in lower extremity Raynaud's is excellent. Scleroderma of face and neck is greatly benefitted. Patients under 55 years of age with Buerger's or arteriosclerotic peripheral vascular disease should have a prophylactic sympathectomy. The author advises sympathetic block as an aid in prognostication. He also sets down the criteria for case selec- tion for hypertensions. MANZANILLA (133) writes on sympathectomy of the upper extremities. BCHLIN (13*0 gives a very interesting case report involving a lower extremity amputation complicated "by a severe "phantom pain," Lurahar sympa- thectomy was done under local anesthesia. The intact chain was stimulated electrically. So was the caudad and cephalad end of the then cut sympathe- tic chain and pain was produced hy all. He concludes that pain sensation Is carried hy certain sympathetic fibers and that Daupe's theory is wrong (ef- ferent stimulll cause pain). (Bd: Interesting, hut requires further con- firmation. ) BOTD and MONRO (135) present a general review of the subject of para- vertebral sympathectomy. Results of lumbar sympathectomy for relief of Ray- naud's disease, immersion foot, livedo reticularis, acrocyanosis, arterio- sclerotic occlusion, thromboangitis obliterans, phantom limb and hyperten- sion are cited. JOHNSTON (136) discusses the use of chemical and surgical Interruption of the sympathetic pathways in peripheral vascular sclerosis, major and min- or causalgia, the various sequelae of thrombophlebitis, hypertension and con- genital megacolon. The author feels that interruption of sympathetic path- ways was definitely indicated for these conditions. LAIJTRB (137) draws on experience gained in over 100 sympathectomies to offer several well-considered "do's" and "don't's" in this field regard- ing selection and technique. He discusses the Indications for and the re- sults that can be expected from gangllonectomy in the common and also the less-often-seen occlusive and vasospastic conditions of the extremities. The miscellaneous discussion Includes seven articles. MBYBR-IAACK (138) attributes spectacular success and improvement In three cases of Su- deck's syndrome to roentgenotherapy. His first case was that of a hB year old man with fracture of the os capitate with degeneration and alteration of the surrounding bones. He had marked incapacity extending over a period 105 of at least eight months. He was treated with 120 roentgens to the rlgfrt cervical field, the right axilla, and the right hand. Three months later, he was given 200 roentgens. Three months after the first treatment, the pain had disappeared, function was normal, and os capitate showed x-ray evidence of consolidation and the spotty alteration of the radius and metacarpal hones had disappeared. The second case described by the author was that of a woman of 62 years who showed spotty atrophy of the patella and femoral condyle, following arthritis. She received 150 roentgens with a repetition of 150 roentgens after an interval of four weeks. Pour months later function was fully restored and the spotty degeneration had disanpeared from the x-rays. The third case was a 58 year old concert pianist who had a severe pseudo- atrophy of the radius. He received similar treatment and had an immediate decrease of pain with ability to play the piano in a concert six months lat- er. VERBIEST (139)'reviews the literature concerning torticollis, and the conclusion is reached that nothing is definitely known about these mechanisms. Electromyography, partial anesthesia with pentothal, and thorough psychiatric examination are considered important diagnostic aids in differentiating be- tween organic and functional torticollis. Three cases of spasmodic torticol- lis treated by cutting the upper three anterior cervical roots bilaterally and intradurally and cutting the accessory nerve either in the posterior fos- sa or in the neck are presented. The neurosurgeon*s purpose is to modify the activity of the defective nervous system in a favorable sense by sup- pressing other active parts. Two cases of dystonia and choreoathetosis treated by cortical ablations are presented. It is stated that anterolater- al cordotomy would have been equally justified. The author reports that the first results of these operations, both collected from the literature and from his own experience, are encouraging though far from the ideal. TSCHANNM and SONNMCHEIN (IhO) discuss the theoretical effect of ul- trasonic waves on arthroses and related conditions. They conclude that the action of ultrasonic results is via a primary reflex which decreases the tone of the skeletal musculature. They are of the opinion that muscular hy- pertonia can be considered the most Important pathogenic factor for arthro- sis, e.g,, from the ultrasonic wave producing hypertonia of these muscles, formerly believed to be in a state of hypotonia, with resultant degeneration of the joint surface. HUDDLESTON et al (1*4-1) report the use of electromyography in the diag- nosis of neuromuscular disorders. Electromyography has three important ser- vices to offer in the management of neuromuscular disorders: (a) differen- tial diagnosis, (b) prognosis, (c) assistance in treatment. The apparatus used in this article is described in detail,. KISSELL et al (1*42) experimentally demonstrate the importance of peri- pheral stimuli in the genesis of the "phantom extremity." A non-amputation case with total paralysis of the brachial plexus is reported. JMSSN (1*4-3) states that psychosomatic musculoskeletal symptoms are atypical in character, anatomical distribution and radiation, and do not respond to the usual therapeutic regimes. The patients are often psycho- neurotic and may show accident proneness. The psychosomatic problems of amputees are stressed. Treatment should be given by the family doctor which 106 consists of rest, sedation, physical therapy and psychiatric consultation in major problems. OVSRBEEK (144) observed the curves obtained in the Fverse-Be Fremery test in normal and adrenolectomized rats. Adrenalectomy caused abnormally low curves after nerve stimulation and also after direct muscle stimulation. 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Talbot, S.r Considerations of palliative operations for paralysis of external popliteal sciatic nerve, Rev. orthrop, 36s Jan-Mar 1950 95» Schwensen, O.s Peroneal paralysis following penicillin therapy of lung abscess, Ugoskr. laeger, 112s 594-5. Apr 27, 1950 96. Denlsart, P.s Severance of the anterior tibial nerve at the upper portion of the leg; secondary suture on the 60th day; cure, Mem. Acad, chir., Par., 76s 523-5, May 17-24, 1950 97. Baker, G, S.s Spinal cord injuries, Minnesota M,, 32s 1094, Nov 1949 98. Levin, I. M.s Spinal cord injury in a premature infant, Proc. Inst. M. Chicago, 17s 406, Nov 15, 1949 99* Becker, H.s Muscle tonus following injury of the spinal cord, Nerven- 113 arzt, 21: Mar 1950 100* Kune, Z,: Present status of surgical treatment of injuries of the spinal cord and cauda, 7oj, zdrav, listy, 19: 110-6, May-June 1950 101. Colling, K. G., and Hossiter, H. J.: Cholinesterases of cerebrospin- al fluid; data for normal fluids and fluids from patients with syphil- is, meningitis, or poliomyelitis, Canad. J. Pes., 27; 327-**0, Oec 19^9 102. Lehoczky, T. von: Differential diagnosis and therapy of myelopathy, Schweiz. Arch. Feur, Psychiat., 65: 1950 103* Bastagll, D,: Acute infectious diseases of the spinal cord. II. Two forms of acute benign Infectious myelitis, Acta med. ital mal. infett., 5: 1-5, Jan 1950 Ungley, C. C.: Subacute combined degeneration of the cord; response to liver extracts; trials with vitamin quantitative method of as- sessing neurological status. Brain, Lond., 72: Sept 19^9 105* Steckelmacher, S, A.: Combined degeneration of the spinal cord in pi- tuitary insufficiency, Acta med. orient., 9: 161-7, June 1950 106. Binde, H.r Effect of intralumbar injections of formol toxoid in two ca ses of severe postdiphtheritic paralysis, Med. Wschr., b: 537-9* July 1950 107* Kissel, P., and Arnould, G.: Arthropathic form of syringomyelia, Pev. med. Fancy, 75: 208-12, May 1-15, 1950 108, Bazzi, T.; Anamalous segmental forms of syringomyelia; cllnlco-statis- tical contribution, Hass, neuropsich, U* 257-69, May-June 1950 109* Paley, S, S., and White, M. I,: Hemophilus influenzae meningitis in an adult with recovery; report of a case, Harlem Hosp. Bull. F. Y., 2: 55-7* Sept 19^9 110. Hazelrigg, T,, and Haven, H.: Spinal cord tumors; some diagnostic problems, Bull, Mason Clin., Seattle, 3: 8-19, Dec 19^9 111. Thompson, C, E,, and Rice, M, L., Jr,: Secondary amyloidosis in spin- al cord injury, Ann. Int. M,, 31; 1057-65, Dec 19^9 112. Danaraj, T. J.: The cerebellar aspect of nutritional spinal ataxia, Tr. H. Soc. Trop. M, Hyg., Lond., Fov 19^9 113. Soule, A, B., Jr., and Stiff, D, W, S.s Changes in the bones and soft tissues in paraplegia. Bull. U. S. Army M, Dep., 9: 1018-21, Dec 19^9 Meirowsky, A, M,, and Scheibert, C. D,; Studies on the sacral reflex arc in paraplegia; clinical observations on inhibitory impulses within the sacral reflex arc, Exp. M. & S,, 8; if-37-8, May-Fov 1950 115. Dane, P. G.: Longevity of paraplegics, Med. J. Australia, 2: 7^6, Fov 12, 19^9 114 116. Guttman, L.r The principles of physiotherapy in the treatment of spin- al paraplegia. Physiotherapy, Lond,, 35: 157-6*4, Oct 19^9 117* Ironside, H,; Multiple cranial and peripheral neuropathy, Proc. R, Soc. M,, Lond,, *42; 793* Oct 19*49 118, Thomas, A,, Ajurlaguerra, J,, and Vargues, R,: Disorders of muscular tonus in spasmodic familial paraplegia, Rev, neur., Par,, 82: 198- 20*4, Mar 1950 119. Blckerstaff, E, R,s Hereditary spastic paraplegia, J. Neur, Lond,, 13: 13Wtf, May 1950 120, Garland, H. G,, and Astley, C. S,; Hereditary spastic paraplegia with amyotrophy and pes cavus, J, Neur, Lond,, 13: 130-3» May 1950 121, Schwartzraan, J.: Transient hemiplegia associated with febrile convul- sions; report of case, Arch, Pedlat., N. Y,, 66; *489-91, Nov 19^9 122. Baruk, H,, and Youchnovetzki; Hemiplegia in a child following tonsil- lectomy, Rev, neur,, Par,, 82; 198, Mar 1950 123. Zweighaft, J. F. B,j Hemiplegia following tonsillectomy, Anesthesiol- ogy, 10; 729-32, Nov 19*49 12*4, Chusid, J, G,, Robinson, F,, and Margules-Iavergne, M, P.; Transient hemiplegia associated with cerebral angiography (diodrast), J, Neuro- surg,, 6; *466-7*4, Nov 19*49 125. Mau, C,; Treatment of spastic hemiplegia by Stoffel-Silfverskiold modified operation, Zschr, Orthop,, 79: 365-83, 1950 126. Covalt, D, A,, Yamshon, L. J,, and Nowicki, 7,s Physiological aid to the functional training of the hemiplegic arm. Am. J, Occup, Ther., 3: 286-9, Nov-Dec 19*49 127. Newman, M. K,, and Cohen, L.; Physical medicine and rehabilitation in the management of hemiplegia in the adult, J, Michigan M, Soc,, *49: 917-22, Aug 1950 128. Baruk, H,# and Hunagedr Mental/derangements associated with Paget's Disease of bone, Ann. med. psychol,, Par., 107: 323-5* Oct 19*49 129. Haverfield, W, T,, and Keedy, C,; Neurosurgical procedures for the relief of intractable pain. South. M. J., *42; 1076-8, Dec 19*49 130. Paillas, J, E., Duplay, J., and Bonnal, J.; Prefrontal leukotomy and topectomy in the treatment of intractable pain; 9 observations, Mar- seille chir., 2; 303-8, Mar-Apr 1950 131. MacCarty, C, S.; Surgery of the sympathetic nervous system, J. Lancet, 69. 377-3*4, Nov 19*49 132. Evans, J, A,; Selection of patients for sympathectomy, Wisconsin M. 115 J.t 48: 991-6, Not 1949 133* Manzanilla, M. A,, Jr,: Sympathectomy of the upper extremities; anato- mo-physiological concept, Medlcina, Mex,, 30: 197-200, May 10, 1950 134. Bchlln, P,j Pain responses on stimulation of the lumbar sympathetic chain under local anesthesia; a case report, J. Neurosurg,, 6: 530- 3, Not 19^9 135* "Boyd, J, D,, and Monro, P. A, 0.: Partial retention of autonomic func- tion after peraTertehral sympathectomy; intermediate lumhar sympathetic ganglia as the probable explanation, Lancet, Lond., 2: 892-5, Nor 12, 1949 136. Johnston, J. H., Jr,,: Indications for chemical and surgical interrup- tion of the sympathetic pathways, Mississippi Doctor, 27: 351-9* Jan 1950 137* lautre, K, A.: The widening scope of sympathetic interruption in les- ions of the extremities, S, Afr, M. J., 23: 1055-8, Dec 31* 1949 138. Meyer-Iaack, H.s Sudeck'3 syndrome and roentgenotherapy, Strahlen- therapie, 82; 231-46, 1950 139* Verbiest, H,: Neurosurgical experiences on the treatment of spasmodic torticollis, athetosis and parkinsonian tremor, Pol, psychiat, & c, neerl., 52: 204-26, Jul-Aug 1949 140, Tschannen, F,, and Sonnenchein, V,: Neuropathologic Tlewpolnts on ul- trasonic therapy of arthroses and related conditions. Praxis, 39: 743-5. Aug 24. 1950 141, Huddleston, 0. L,, Golseth, J. G,, Marinacci, A, A,, and Austin, B.: The use of electromyography in the diagnosis of neuromuscular disorders. Arch. Phys. M,, 31: 378-37* June 1950 142, Kissel, P., Housseaux, R., and Ren, G,, de: Phantom limb due to the resection of the axillary artery in a nonaraputation case affected with total paralysis of the brachial plexus, ReT, neur., Par,, 82: 131-2, Feb 1950 143* Jensen, W, P,; Psychosomatic disorders of the muscles, bones and joints, Nebraska M. J., 35: 179-81, June 1950 144, OTerbeek, Vies J. Tan derr Adrenals and fatigue; an analysis of the influence of adrenalectomy on the muscle and on neuromuscular trans- mission, Arch, internal, pharm, dyn., 83: 296-307* July 1, 1950 116 CHAPTURE VIII FRACTURES By Oscar S, Reeder, Colonel, USAP, (MC) Office of the Surgeon General Washington, D. C* I. General A. Treatment B. Research C. Complications II. Head and trunk A. Head B. Vertebrae C. Pelvis III. Upper extremity A. General B, Humerus C. Radius and ulna D, Hand IV. Lower extremity A. Hip region B. Pernor C. Patella, tibia, and fibula D. Foot In this chapter, articles are abstracted. Several could not bo translated in time for publication and a few were not received. General There are four articles dealing with the subject of treatment. CLEVE- LAND (l) reviews the general situation in regard to the emergency treatment of bone and Joint casualties as it existed in World War I and World War II, Emphasis is placed on the primary closure of wounds, forgotten between the two World Wars. The closed plaster technique, popularized in the Spanish Civil War had become a deeply ingrained surgical concept. In order to eval- uate the success of delayed primary closure of wounds over compound frac- tures, a study was undertaken at a hospital center. During a five month per- iod after the invasion, primary closure was attempted in 2393 patients. Com- plete healing by primary intention occurred in 1592 cases, or 66.5 per cent of the total. Partial failure occurred in cases or 26,7 per cent. In almost all of these, healing took place before the patient left the hospital. This meant that about 93 per cent of patients on whom delayed primary clo- sure was attempted were returned to the Zone of the Interior with healed 117 wounds. The success of these closures was determined "by the completeness of the original wound excision. In a series of similar size in which no clo- sure had been attempted, an incidence of osteomyelitis of per cent ap- peared. This reduction in osteomyelitis from per cent to lh per cent by delayed closure of wounds over compound fractures, should answer the ques- tion of how these cases should be managed. Skeletal traction is the safest and simplest method of mass treatment of compound fractures of long bones caused by gunshot or high-explosive shell. Evacuation of the patient from overseas to the Zone of the Interior should be in circular plaster-of-Paris splints. Internal fixation should not be undertaken until after wound heal- ing. There were 3190 long bone compound fractures received from the Euro- pean Theatre at the 19 general hospitals in the Zone of the Interior which participated in this report. The status of healing of these fractures, four to six months after injury are as follows: 68.6 per cent wore satisfactor- ily united, 13.3 per cent had united in malposition, and 18 per cent were ununited. Many, due to loss of bone by the wounding agent or to the over- zealous removal of bone fragments, required years of repeated bone-grafting procedures to bridge a gap or loss in continuity. Wounds of the hand com- prise two per cent of all wounds. Prom the time of injury every effort should be directed to salvaging all possible damaged tissue and to restor- ing function. A meticulous cleaning is Important. The debridement should be done carefully so that all possible tissue can be conserved, especially viable skin. Primary closure by suture or split thickness graft is recom- mended. (Ed: It is believed that wounds of the hand caused by high explo- sive shell fragments are preferably managed by initial debridement and de- layed closure on the fourth or fifth day if no infection exists.) As the art and science of surgery has progressed, amputation has diminished in fre- quency. The incidence of amputations in World War II was approximately one- tenth that in the American Civil War. Amputation is now resorted to only when an extremity is irretrievably damaged. For emergency amputation an o- pen circular type at the most distal point possible is safest and most de- sirable. Continuous skin traction usually results in closure of the stump. The definitive amputation can then be done with greater safety later at an elective site. The major joints are frequently involved and their early management determines their later course. If there is a perforating wound of the joint, a wide surgical exposure should be done with careful excision of damaged soft tissue and cartilage and removal of all available foreign bodies and the joint cavity irrigated. The synovial membrane and capsule should be closed with instillation of penicillin into the closed cavity. The skin and superficial tissues should be left open widely and the extrem- ity should be immobilized. After Zk hours the joint may be aspirated and the antibiotic again Instilled. Closure of the superficial wound by suture or skin graft should be accomplished three to five days after wounding. The safe and comfortable transportation of the casualty with a compound fracture is of utmost importance to minimize further trauma. Emergency splints should be applied at the point of first aid. Following wound exci- sion, the application of appropriate plaster casts, completely split to al- low for swelling, are advised. 0*MEARA (2) presents his views on the safe management of fractures be- fore the Massachusetts Medical Society. He gives a complete review of the historical advances of the past century and in conclusion recognizes the trend toward surgical management. The major surgical means are Internal fixation, external fixation, and intramedullary nailing. He warns that open 118 management of any type Is more hazardous than closed, and that the major Joh of the doctor is to restore function quickly and completely, If he can, hut hy all means, safely* JOHN SON and STOVALL (3) report on external fixation as a method of treatment of fractures* Questlonalres were sent to all members of the Am- erican Academy of Orthopaedic Surgeons, the American Association for the Surgery of Trauma, and one of the state medical associations* From the 3082 questlonalres, 768 replies were received and 395 replies were considered for analysis and subdivided into three groups as follows! Zh per cent found this method to have a definite place In fracture management, 29 per cent found it inadvisable, except in rare instances, and per cent had at one time used this method but have discarded it completely. The reasons for disapproval were: (a) as good or better results were obtainable by other methods which these physicians felt were less time consuming, less difficult mechanically, and attended by fewer of the complications of infection, (b) poor reduction, (c) poor immobilization, and (d) malunion or nonunion* The advantages list- ed were: (a) more secure and adequate immobilization, (b) early ambulation, (c) shorter period of hospitalization, (d) simplicity and speed of applica- tion, (e) reduction of nursing case, (f) early motion of Joints, (g) the maintenance of bone length, (h) absence of nonunion, (i) absence of distrac- tion, (j) minimum surgical risk, and (k) reduced period of time required for application* In conclusion, the authors recommend that any individual who contemplates using this method of treatment acquire special training under the supervision of an individual who has treated at least 200 eases by this method* GEDALEVICH W reports his results with osteosynthesis of infected gun- shot fractures* Two articles on research are abstracted. In a study of fracture heal- ing by means of radioactive tracers BOHR and HALBORO (5) use P-32 and on rats to determine whether the metabolic processes are localised in the immediate area of the fracture or whether the whole skeletal system is in- volved. They found that the phosphorous-nitrogen ratio decreased during the first 20 days after fracture, returning to normal in about 50 days. The authors failed to find support for the conclusion of Roche and Morgue that all the bones in an animal with an induced fracture take part in the pro- cess of healing. They did find, however, that activity appears also in the metaphyseal and epiphyseal parts of the bone, even though remote from the fracture site. SACHAR et al (6) confirm previous observations that there is an ab- normal loss of nitrogen following trauma, a phenomen usually referred to as the catabolic phase, and he concluded from his study that seven of 12 pa- tients who incurred severe fractures showed an Initial loss of sugar toler- ance, which gradually was regained as the catabolic period waned, and that in six of the 12 cases changes in the sugar tolerance were sufficient to place the patient in the "diabetic" group, and that the loss of nitrogen after trauma is not associated with marked changes in the level of ketonemia as it is during fasting* Two authors write on complications. TODRHRTX (7) reports on a lecture on venous embolism in closed fractures, outlining the differential diagnosis 119 between fatty embolism and Tenons embolism, and discussing the historical aspect of the condition, and its pathology* In agreement with Barber, the author lists five different types of embolic accidents: (a) in the syncopal type a large infarct is stopped in the right heart causing sudden death, (b) the choking peracute type when the infarct stops at the level of the trunk of the pulmonary artery: the patient is suddenly overcome by suffoca- tion, (c) the acute asphyxlal type, in which a large pulmonary infarct de- velops leading rapidly to cardiac failure, (d) the subacute asphyxial type, an infarct of the terminal limbs of the pulmonary artery, represented by the clinical picture of localized pain, intense dyspnea and hemoptysis and usu- ally recovery, and (e) the undetermined type, often taken to be bronchitis* SPINOLA (8) explains the modus operand! of displacement of fracture fragments by the uncoordinated muscle action which results from the fracture* He conclules, that to succeed in maintaining the fracture in position after reduction, the compression on the fleshy masses surrounding the bones ap- plied through the cast, or other means, must be sufficiently intense to re- sist the resultant force which forces displacement of the fragments* Head and Trunk There were no articles abstracted on fractures of the head* Two auth- ors write on fractures of the vertebrae. ROCHE (9) reports a case of bilat- eral fracture of the pars Interarticularis of the third lumbar neural arch, without dislocation, in a 22 year old man, whose Jeep overturned* He was immediately placed on a Stryker frame and roentgenograms showed the fractures involving both isthmi of the third lumbar neural arch, without dislocation of its vertebral body. The period of recumbency was 1? weeks* Roentgeno- grams at the end of that period showed obliteration of the fracture lines* The patient was re-examined 26 months after injury* He had worn a Taylor brace for six months following the recumbency, had been regularly employed at clerical work and had no symptoms* Roentgenograms demonstrated healing of the bone* FISHER and MAXWELL (XO) suggest a simplified method for treatment of compression fractures of the lower hack* The patient is suspended prone by a Zimmer clavicular strap applied about the shoulders and a stout rope quad- rupled, is attached to a ceiling fixture* The patient*s head is held in the anesthetists lap to maintain an adequate airway* The patient's thighs and arms are supported by tables or assistants* The operator may manipulate the back by placing his right knee under the symphysis pubis, the left hand under the sternum and reducing the fracture with the right hand* A light, snug-fitting plaster cast is applied* The method is simple and cheap* Pertaining to nelvlc fractures, CORRADI (ll) describes a vertical fracture extending from the top of the sacrum to the distal end of the coc- cyx; vertical fractures of the right and left ischiopubic Junctions; sub- luxation of the symphysis pubis with upward displacement of the left rams* The traumatic mechanism which caused the fracture is considered by the auth- or to have been the impact against knees transmitted through the femurs and resulting in a disruption of the pelvic girdle and a giving away of the sac- rum* Unuer Extremity 120 The one article on the tipper extremity In general le hy SCHWARTZ and HAHMOH (12) who report on their experiences in the treatment of 30 fractures of the shafts of the long hones, chiefly the htxmertis, the forearm and the tlhia, utilizing medullary fixation hy threaded vires and pins of various sizes of 18-6 SMO stainless steel* The diameters of the pins used ranged from 1/8 inch to 7/32 inch and from six to 35 Inches in length. The auth- ors discussed the techniques used for individual hones* The results as stat- ed hy the authors are quoted as follows: "There were no instances of nonun- ion and no infections. Solid union to physical examination was often pre- sent in 12 weeks.” In a discussion of fractures of the humerus BOSWORTH (13) proposes the use of hlade plates for fractures of the surgical neck. He states that in the past, treatment of these fractures has consisted of essentially no treat- ment whatsoever. He agrees that many, perhaps most, such fractures are not displaced sufficiently to demand replacement, progress uniformly to union and provide a stable and useful extremity when united. His attention was first directed to this problem hy a patient in whom osteotomy was necessary for congenital humerus varus. A regular vita Ilium plate sharpened on one end and bent to the proper angle was used. The second case concerned a dis- placed fracture of the surgical neck of the humerus in a laborer, impossible to reduce by closed methods. SMITH (1*0 discusses medial epicondyle injuries and states: (a) injury to the medial epicondyle of the humerus is common, but it is not usually a serious injury, (b) the most important diagnostic point to remember is the possibility of displacement of the medial epicondyle into the elbow joint, (c) all epiphyseal ossification centers must be discernible in their normal locations by roentgen examination, (d) treatment should be based upon the conditions present and should be instituted early. Conservative treatment is indicated in all cases except those in which intraarticular displacement of the epicondyle has occurred or in which ulnar nerve damage has taken place, (e) the physician should minimize the period of immobilization and institute early active exercises within pain limits, (f) the physician should avoid prolonged immobilization, passive stretching, weight carrying, and late op- erative treatment, (g) the status of the ulnar nerve should be checked be- fore treatment and frequently during treatment (the nerve should be treated if indicated), and (h) the prognosis for this injury is excellent If the condition is treated early and wisely and is not overtreated. In the treatment of fractures of the radius and ulna, SALASC (15) pre- sents a case report of a fracture of the olecranon process treated by exci- sion of the one and one-half inch fragment. After Immobilization in a light plaster cast for hours, freedom of motion of the elbow was allowed. Rive months aftei; all the elbow movements were normal. PATHTO (16) presents his method of fixation of compound fractures of the middle third of both bones of the forearm. Plates with screws are con- sidered intolerable. Thin wires placed longitudinally do not prevent dis- placement in an anteroposterior direction. The author prefers, in the man- agement of exposed fractures, treating the wound area and fracture site with penicillin, and immobilization with a Clayton type splint for about 72 hours. If infection is under control at this time, surgical reduction is made and osteosynthesis of the radius is accomplished with a thin silver wire. In 121 addition two Strader duraluminum and steel nalle are inserted for external fixation# CASSEBAUM (17) reviews J6l patients with Colles' fracture and the end results in 81 cases. All the patients studied were treated by manipulative reduction and plaster splints. Badly comminuted and oblique fractures are difficult to reduce and still more difficult to hold. Since this study, the authors more frequently use splints immobilizing the elbow. Permitting el- bow motion is a frequent cause of motion at the fracture site, with conse- quent loss of position. In their experience immobilization in marked palmar flexion results in a painful, prolonged convalescence. Dorsal tilting is one of the most pronounced anatomic deformities of Colles' fracture, but is the least disabling. Radial deviation of the wrist and shortening, with the resultant disturbance in the radtolunar joint, are greater functional handi- caps. Pain or aching associated with changes in the weather not infrequent- ly persists for as long as a year after severe Colles* fracture. Wringing clothes, turning a tight door knob, heavy lifting and pronation and supina- tion movements under stress are frequently painful for a year after injury. Happily, few patients have pain after this time even when they retain con- siderable deformity. The following are common violations of principles: (a) rocking the fracture back and forth to break up the impaction, an action which further comminutes the fracture and injures the soft tissues, (b) ap- plication of splints without anticipation of further reactive swelling and edema, (c) neglect of shoulder and finger exercises, (d) Inadequate immobil- ization due to poor splints or too brief a period of immobilization (under five to six weeks in patients with deformity), (e) immobilization in marked flexion, which position is painful and interferes with circulation, and (f) failure to make the patient understand the Importance of early function of the fingers. In fractures of the hand ROEMER (18) describes two types of hyper ex- tension Injuries to the finger joints, and concludes: (a) the common "base- ball" or "mallet-finger” is frequently due to forceful hyperextension of the distal phalanx on the middle phalanx, (h) a similar injury occurs at the in- sertion of the middle slip of the extensor tendon at the middle phalanx. This results in a typical and very disabling type of deformity, the differ- ential diagnosis and treatment of which is described, (c) spicules frequent- ly seen in x-ray on the volar aspect of the interphalangeal joints resemble sesamoids but are usually avulsion fractures at the distal attachment of the joint capsule due to hyperextension or a direct crushing force. 0 * CORNELL (19) reports on an unusual compound fracture. A milkman on a delivery tricycle was involved in a collision with a similar vehicle. His left hand resting on the handle bar was driven forcibly against the bell which was fixed to the bar. Radiographic examination showed that the lever of the bell had penetrated the lateral cortex of the neck of the second met- acarpal. The bone cavity was curetted and $00,000 units of penicillin solu- tion were instilled into the wound. Three weeks after the injury the wound was firmly healed. Flexion of the metacarpophalangeal joint was limited by 10 degrees but other joint movements were normal. Lover Extremity In an article on fractures about the bin region. LEWIS et al (20) pro* 122 sent their observations and conclusions based upon a study of 152 consecu- tive patients with intracapsular fractures of the neck of the femur* All cases were treated by nail fixation* Of the 106 patients who could be fol- lowed for at least a year, 79 (74.5 P«r cent) obtained union* The authors consider that the occurrence of late aseptic necrosis of the head of the fe- mur has been very infrequent, and they conclude that, to avoid nonunion,#the redaction must be good, the nail must be long enough to reach well into the head, the fragments must be well impacted, unsupported weight bearing must not be undertaken for six months, and the operation must be performed only by experienced surgeons* ZOLE (21) describes a sighting mechanism for piecing the guide wire in the neck of the femur during the operation for internal fixation of a fracture of the neck of the femur. The fracture is reduced, by manipulation. The axis is arranged by application of Jeschke wire net and x-rays are taken at both levels. Nails are then inserted to mark the head of the femur and a third nail in line with the two preceding nails is placed in the shaft, one inch below the tip of the trochanter* An incision is made to expose the area of the greater trochanter; cne sees the third nail lying alongside the lateral surface of the femur. Where this nail touches the femur is the ex- act point at which the guide wire must be introduced. The assistant inserts the Zirschner wire by hand by sighting on the first and second pins. It is determined by x-ray that the guide wire is in good position and the Boehler nail is driven in. The author states that the actual length of the opera- tion, including the taking of x-rays is about 25 to JO minutes. (Ed: The original article contains a drawing of the Jeschke net superimposed over a diagram of the upper end of the femur.) DE PAIMA (22) presents a preliminary report on hO consecutive cases of transcervical fracture of the neck of the femur which conform to Pauwel*s Types II and III. Wedge osteotomy through the neck of the femur is offered as a simple and effective procedure for converting sheering forces of the fracture site into compression forces. The lower incidence of aseptic ne- crosis may ho due to the rapid healing process that takes place at the frac- ture site when the femoral head is placed and fixed in the position of val- gus. Longer follow-up studies are necessary before the final incidence of capital necrosis can he established. MILLER (23) reports a case with stress fractures of the necks of both femurs in a white stenographer, age J6% She complained of pain in both hips for two months. The patient walked with the hips flexed, the pelvis tilted backward and both lower extremities held in adduction. Attempts at abduction of the hips produced pain in the inguinal region on each side. Anteroposterior roentgenograms of both hips showed an area of dehiscence ex- tending through the inner aspect of each femoral neck at approximately the point exposed to most stress* The fracture line was widest at its innermost point and gradually faded. Hubbard-tank baths and general massage gave im- mediate relief and she was allowed to bear weight with crutches for three months. In eight months the patient was free from all symptoms and had re- turned to work. Anteroposterior and lateral roentgenograms of both hips shoved complete healing. PETERSON (24) in a comprehensive survey of the literature, could find reports on only 13 cases of simultaneous fractures of the neck of the femur and dislocation of the femoral head. One of the cases was reported by Funs- ten et al. The other case was reported hy Hart. In this paper, two addi- tional cases are presented; one is a personal case, and the other, which has not been reported previously, was contributed hy a colleague, J. A, Freiberg. The author*s case is reported in detail with an evaluation of the result aft- er a period of seven years. The prognosis of unusual injury is far less fav- orable than that in other types of fracture-dislocation involving the hip. The author chose to reduce the fracture and to Insert a graft. Removal of the femoral head followed by a reconstruction operation is the treatment of choice. Available reconstruction measures are as follows: (a) insertion of the neck, (b) primary fusion, (c) trochanteric cup arthroplasty, and (d) pri- mary replacement of the head by a device such as a metallic prosthesis. LEFaTTEAL (25) reviews 20 cases of intertrochanteric fracture of the hip treated on the Orthopedic Service of the University of Pennsylvania Hos- pital. He agrees with Cleveland, Bosworth, and Thompson that these patients, in spite of their age and poor physical condition, withstand anesthesia and surgery surprisingly well. The mortality rate is definitely lowered. Intern al fixation of the fractures facilitates postoperative care and reduces the incidence of serious complications. RIHIUNAU (26) states that he has used Jewett nails very successfully in intertrochanteric fractures of the femur. He mentions the seriousness of these fractures, quoting the 30 per cent mortality rate published by Mather Cleveland and Horton, and implies that thromboembolism has been found to be a major causative factor in this high mortality. He further remarks that perventive ligature of the femoral vein (Norton, Linton) to prevent any em- bolism is an advance in the management of these cases. SCHELDT (2?) discusses the so-called "plug fixation** method of provid- ing internal fixation for pertrochanteric fractures of the femur advocated by Hauck and Bako. The method consists essentially of the placement of two to four wires across the fracture site, leaving the wires protruding from the skin. The method has two serious disadvantages: first, the danger of infection, and second, likelihood of displacement of the fracture. In an ef- fort to improve the results the author modified the technique, essentially by having the wires lie subcutaneously. A plaster splca is then applied. (Bd: This appears to be a local controversy. The author points out that the idea was not originated by Hauck and Bako because Moore bad used three nails for the same purpose.) YAH HD7E (28) reports a detailed study of an isolated fracture of the lesser trochanter in a patient, ago 14, who Incurred the fracture while run- ning, after which he walked home. Two years after the accident, running was still not normal and he tired easily. In a review of the literature, the author found 64 other cases. From the background of the literature, the et- iology, pathological anatomy, pathogenesis, differential diagnosis, treat- ment, and prognosis are discussed. MARCHAHD (29) reviews his methods of management in 150 fresh fractures of the femur in children. The methods used were as follows: 19 reductions by continuous horizontal extension; 90 reductions by continuous vertical ex- tension; six reductions by traction applied with a Kirschner pin; 23 surgi- cal reductions with a metal plate; seven reductions by centro-medullary 124 piercing with a Steinman nail; one case of internal fixation with a screw; and finally, fire fractures were immobilized by means of a plaster cast* 37 per cent were graded as excellent, 50 per cent as good, and two per cent as poor. Hospitalization lasted on an average of 29 days for closed reduc- tions, 22.2 days for fractures internally fixed with plates, and 19*3 days in the cases of centro-medullary piercing. Current practice is vertical ex- tension for children six years old and under. With the older children, hor- izontal traction is used with or without the Kirschner pin. The medullary nail is preferred in fractures of the upper third, while plates are chosen when the fracture is in the medium-low or definitely low diaphyseal fractures. The intervention is followed by immobilization in a cast for six weeks. The Steinman nail is removed after about six weeks; embedded plates are removed after six months. FITTER SON and REEDER (30) discuss the use of dual slotted plates in fix- ation of fractures of the femoral shaft and report on 18 cases treated by this method. Internal fixation of fractures of the femoral shaft by two slotted plates is advocated for the treatment of fractures in which intern- al fixation is Indicated for malposition, nonunion, or malunion, or in which open reduction is the treatment of choice. The report includes a series of 18 fractures which were treated successfully by this method. The absolute rigidity and contact established by two slotted plates make it possible to dispense with external immobilization, and the patient may bear weight with- out restriction as early as a week after the operation. SMITH (31) discusses intramedullary fixation. In October, the Surgeon General's Office, Department of the Army, authorized a substantial grant through the National Research Council for an extensive clinical inves- tigation of intramedullary fixation. More than 18 months were consumed in designing and redesigning pins and instruments which were mainly modificat- ions of the Ideas of Kuntscher, Habler, Hansen, Street, Bohler, and others. All efforts were concentrated on improving the equipment for the femuri In June complete sets of intramedullary equipment either for the diamond- shaped pin or the clover-leaf pattern wore considered adequate and were dis- tributed by the Army to 20 groups of investigators; three to the Army gener- al hospitals, two to veterans facilities, and 15 to civilian groups. As of January 1, 1950, 398 intramedullary pins had been inserted. A detailed an- alysis of cases will be carried out at a later date, (Ed: The final re- port of this group was in the form of a Symposium of 700 femurs in Instruc- tional Course Lectures, American Academy Orthopedic Surgeons, 1951* J# W. Edwards Co,, Ann Arbor, Michigan,) STREET (32) compares treatment of fractures of the femur by skeletal traction, dual plating, and medullary nailing. He begins the discussion by stating that treatment of fractures in the femoral shaft has undergone a process of evolution in which the five main mechanical principles have been developed. The oldest method, that of reduction by manual traction and man- ipulation, followed by external fixation was extensively employed by Hippo- crates. The second method, that of continuous traction, was Introduced by de Chaullac about 1350* The third method, that of open reduction with wire suture fixation was attempted as early as 1827 by Rogers, The fourth meth- od, external skeletal fixation was originally employed by Bonnet about 1870, The fifth method, medullary nailing, is a form of internal fixation. The author conducted a study of a series of 20 cases and concluded that skeletal 125 tractiont dual plating and medullary nailing are the three most premiaing methods. Hospitalization and total disability are shortest with medullary nailing, which is recommended as a treatment of choice in suitable fractures of the femoral shaft. 7AH DE VOORDE et al (33) report a case of pseudarthrosls of the femur treated by intramedullary nail and graft. In consideration of fractures of the patella, tibia, and fibula, the general principles of fractures of the lateral tibial condyle are reviewed by BRADFORD and KILFOTLE and they add a "therapeutic classification." They believe that the basic mechanism for all fractures of the lateral tib- ial condyle is an impaction of the condyle of the femur against the plateau of the tibia, as a hammer strikes an anvil. In their series of bO cases, three general types were encountered. Type I, the "crush fracture," consists of all degrees of compression of the lateral tibial condyle with mild or ex- treme depression of the plateau. In Type II, or the "split fracture," the condyle, instead of being crushed, is split off with little, if any, depres- sion. In Type III or "shatter fracture," the force of the trauma extends obliquely toward the center of the knee and downward, to break away the sup- port of the shaft or of the medial condyle at the neck of the tibia. The authors concur in general that only those cases with over one-half inch of depression should be considered for open reduction. The results of surgery are apt to be disappointing and conservative treatment will give satisfac- tory results "even when considerable irregularity of the condylar tables persists." The principles of conservative treatment, followed by the auth- ors, have been worked out in detail. First a manipulative reduction is done under anesthesia. The knee is drawn forcibly into varus and with a well-ap- plied cast, which must extend from the groin to the foot. The knee must be forced into enough varus to protect the lateral plateau from compression; this position must be maintained for approximately four months and nonweight- bearing motion must be started early to avoid stiffness of the knee. That is, in 10 days to two weeks, moderate flexion movements are started actively but not passively. The exercises are repeated twice a day, the amount of motion being Increased as fast as the patient can tolerate it. The limb is replaced in the cast after the exercise. By the third or fourth week, the patient can be transferred to a high-thigh, double-upright brace, equipped with straps to maintain varus support. For these cases, the operative pro- cedure is so extensive that it involves more than the ordinary risk of in- fection. The literature is remarkably free from any mention of this hazard, but, even with antibiotics and chemotherapy, the risk remains grave. If the displacement is gross, with fragments large enough to permit some form of internal fixation, the advantages of open reduction probably outweigh the risks of surgery. PIQUE (35) discusses the principal Indications for use of bone grafts in fractures of the tibial tuberosities. When the fracture is not displaced, the nonsurglcal methods offer a satisfactory solution. According to the author, there are three types of displacements: lateral, compression of spongy bone, and a combination of the two. Honsurgical reductions were done by manipulation and lateral compression with Bohler's clamp, Delitala's pres- sers, Cotton's hammer, Roux's forceps, etc. In eight of the authors series of 13 cases, the menisci were ruptured. The author reports satisfactory re- sults in all 13 cases. 126 ROCHST (36) provides a six year follow-up on a case of partial patel- lectomy for fracture in a 59 year old woman. Range of knee motion was com- plete. The author believes that the smaller fragment should he sacrificed whether It is the upper or lower one. Partial patellectomy prevents the formation of the enormous patellae that sometimes form after the best re- pairs. Tavenler, in discussing this paper, made the following remarks: ”1 am in agreement with him with regard to removing always the smallest frag- ment; it is when the fragments are even that I advise removing the upper fragment in order to maintain the normal insertions of the patellar liga- ments ." Scott, an English Surgeon of the Royal Air Force, reported that "It would appear that the results of total patellectomy, although favored by certain English surgeons, are far from satisfactory, that those achieved through suture are better, and that the results of the removal of one of the fragments is much better." STRATER (3?) provides a background discussion on spastic contracture of the calf muscles and describes his operation of resection of the gastroc- nemius muscle and the results of eight cases. Tenotomy of the tendo achti- lls is one of the oldest procedures in the surgical heritage of orthopedic surgery. Stoffel outlined a method of denervating spastic muscles. The author’s impression, gained from examining patients who have had heel-cord lengthening and the Stoffel procedure, has been one of disappointment. In case I it was found that, with the knee in 90 degrees of flexion, the foot could easily be dorslflexed to 90 degrees. This demonstrated that severance of the gastrocnemius from the soleus would allow the patient to place his heels on the floor when walking. Since beginning this work, he discovered that Silfverskiold presented a paper on this subject in 1923* The eight cases in detail by the author all resulted in the patients being able to place their heels on the ground during weight bearing. The operative pro- cedure was given in detail. The immediate operative result desired has been obtained in all cases so far treated. Following the operations, the relax- ation of the scissor gait was marked. In similar fashion these patients were able to use their gluteli and to contract them while in the standing position which they had not been able to do before. This change in the ton- al reflex of these muscles is so fundamental that the patients recover active dorsiflexion of the foot by means of the anterior tibial muscles, which had usually no voluntary control previously. LAUG-B-HARSEN and RAND HR S (38) report findings in experiments in the production of fractures of the ankle. The authors determined the mechanism of fracture, the pathologic anatomy, and the genetic roentgenology. The ex- periments were carried out exclusively on extremities which were amputated at the femur or at the knee. In consideration of fractures of the foot. WILSON (39) discusses his methods of treatment of fractures of the calcaneus. Included also is a thorough discussion of the various roentgenographic views which are helpful in making an exact diagnosis of the character and extent of the fracture of the calcaneus. The author deprecates any operative attempt to replace the fragments of a compressed fracture of the calcaneus in view of the great number that may be present. The introduction of pins is also considered ob- jectionable since they are apt to produce a distressing osteomyelitis, very difficult to cure. The object of treatment should be to restore, as far as possible, the facets to their normal position and this can be accomplished 127 best by closed methods* The setting is a combination of simultaneous trac- tion, pounding and lateral pressure, and is carried out with the aid of fluoroscopy, while assistants exert a strong simultaneous pull and the surg- eon delivers a heavy blow on the felt padded brown handle with a four pound mallet* The blow disimpacts the fragments* When satisfactory reduction has been accomplished, ho can proceed with plaster-of-Paris with the patient prone so that he can compare it with the opposite side* Stockinette is palled over the foot* 1 thick piece of sponge rubber is then placed immed- iately beneath each malleolus and over this plaster is applied. The cast is left on for a month* The patient is encouraged to move the foot in various directions many times a day* The patient should not bear weight on the limb, however, for about eight weeks and then only with the help of cratches and a fairly stout shoe* GECKLER (40) discusses fractures of the os calcls. In a review of 100 cases it was found that the average time lost from work was 18 months, with an average payment of $1,561 for compensation during that time* The author reviews his own cases and expresses his opinion as to how the cases should be managed* The eases are divided into Types A and B, In Type A the frac- tures do not involve an articular surface; while in Type B the one or more articular surfaces are damaged. Fractures in which the heel is not decided- ly displaced need no manipulation* Treatment is early weight bearing in a walking cast, the foot being held in a decided equinus position. More severe injuries, with loss of the tuber angle and marked squashing and tilting, must be treated by reshaping. For fractures which extend into the calcaneocuboid joint a triple arthrodesis is indicated. In 27 cases of fractures of this type and with this treatment, the author reports good in 19 cases (70 per cent), fair in eight cases (30 per cent), and poor in no cases* MICEELE and KRUEGER (4l) give a short discussion of the treatment of fractures of the astragalus and cite two cases. They advise roentgenograms of both feet to identify an os trlgonum. They also advise immobilization of the foot at a right angle for four weeks where there is a mechanical in- terference of the subastragaloid joint. Excision of the entire posterior process of the astragalus is Indicated. Both of the cases cited were treat- ed by removal of the displaced fragment. Follow-ups of five years and two years respectively found that the ankles in both cases were functioning normally and without discomfort. VECCHIONE (42) discusses the incidence, causative mechanisms, and treatment of Isolated fractures of the tarsal navicular and the cuboid and cites three cases* Two were of the navicular, and one of the scaphoid. In each case, crushing by falling objects was the causative factor. Treatment consisted essentially of immobilization in plaster casts* long term follow- ups were not included*. 128 BlBLIOGRAHtY I. Cleveland, M.: The emergency treatment of hone and Joint casualties, J. Bone Surg., 32 Ai 235-48, Apr 1950 2# O'Meara, J, W.; Safe management of fractures, H, England J, M,, 242; 769-73. May 18, 1950 3. Johnson, E. P., and Stovall, S. L.s External fixation of fractures, J, Bone Surg., 32 A: 466-7, Apr 1950 4, Gdalevich, I. N.: Results of osteosynthesis of infected gunshot frac- ture, Khlrurgia, Moskva, —: 77-9. Sept 1949 5# Bohr, H,, and Halhorg, S. A.j Study of fracture healing hy means of radioactive tracers, J, Bone Surg,, 32 A; 567-74, July 1950 6. Sachar, L., Walker, W., and Whlttico, J.: Carbohydrate tolerance, blood ketone levels and nitrogen balance after human trauma (fractures). Arch, Surg., 60: 837-44, May 1950 7. Tourneux, M. J, P,j Venous embolism in closed fractures, Concours mod., 72; 1311-2, Apr 29, 1950 8. Spinola, N.; Causes of displacement of fractured bones and ways of avoiding It, Cac. med, Mexico, 80; 14-25. Mar 1950 9. Roche, M, B,; Healing of bilateral fracture of the pars interarticu- laris of a lumbar neural arch, J, Bone Surg., 32 A: 428-9, Apr 1950 10. Plsher, R. H,, and Maxwell, 0, S.; Simplified method of treating com- pression fractures of the lower back. Am. J. Surg., 80; 106-7, July- 1950 II. Corradi, C,; An unusual fracture of the pelvic girdle. Arch, ortop,, 63: 80-4, Jan-Mar 1950 12. Schwartz-, A, A., and Harmon, P. H.; Threaded wires and pins for long- itudinal medullary fixation of fractures of the humerus, radius, ulna and tibia. Am, J. Surg., 79: 264-75, Peb 1950 13* Bosworth, D, M.; Blade plate fixation; technic suitable for fractures of the surgical neck of the humerus and similar lesions, J. Am, M, Ass., 141; 1111-3, Dec 17, 1949 14, Smith, P, M,: Medial epicondyle injuries, J, Am, M, Ass., 142; 396- 402, Peb 11, 1950 15* Salasc, J,; Fracture of the elbow; resection of the olecranon, Afrlque fr. chlr,, —; 24?, Hov-Dec 1949 16, Maass Patino, J.; Contribution to the surgical therapy of exposed fractures of both bones of the forearm at the level of the middle third. 129 Cir. cirujan., 18; 72-8, Feb 1950 17. Cassebaum, W# H.; Colles1 fracture; a study of end results, J. Am. H. Ass., 1**3; 963-5# July 15# 1950 18. Roemer, F. J.; Hyperextension injuries to the finger joints. Am. J. Surg., 80; 295-302, Sept 1950 19. O'Connell, J. G.r An unusual compound fracture, J. Bone Surg., 32 B; 233# May 1950 20. Lewis, K. M., Boutelle, W. F., and Roberts, M. A.; Intracapsular fracture of the nock of the femur; observations on 152 patients treat- ed by internal fixation with Smith-Petereen nail, Ann. Surg., 131s 376-8**, Mar 1950 21. Foie, V.: Extraarticular osteosynthesis of fracture of the femoral neck, Chirurg., 21; 228-9, Apr 1950 22. De Palma, A. F.; Wedge osteotomy for fresh Intracapsular fractures of the neck of the femur, J. Bone Surg., 32 As 653-62, July 1950 23* Miller, L. F.s Bilateral stress fracture of the neck of the femur; re- port of a case, J. Bone Surg., 32 A: 695-7# July 1950 2**. Peterson, L. T.; Dislocation of the hip associated with fracture of the nock of the femur, J. Bone Surg., 32 A; 27**-9# Apr 1950 25* Leventhal, G. S.s Intertrochanteric fracture of the hip. Am. J. Surg., 80; 303-4# Sept 1950 26. Rleunau, G.; Intertrochanter fractures treated hy Jewett nail, Toul- ouse med., 51; 198-9# Apr 1950 27* Scheldt, R.; Treatment of pertrochanteric femoral fractures, Chirurg., 21; 225-8, Apr 1950 28. Van Hove, R.; Isolated fracture of the lesser trochanter, Acta chir. belg., —: Nov 19**9 29. Marchand, J. C. A.: Comments on fractures of the femur in children, Union med.Canada, 78; 1303-6, Nov 19**9 30. Peterson, L. T,, and Reeder, 0. S.: Dual slotted plates in fixation of fractures of the femoral shaft, J. Bone Surg., 32 A; 532-41, July 1950 31. Smith, E,; Intramedullary fixation, J. Bone Surg., 32 Apr 1950 32. Street, D M.; Medullary nailing of the femur; comparative study of skeletal traction, dual plating and medullary nailing, J. Am. M. Ass., 1**3: 709-1**# June 2**, 1950 130 33* Van de Voorde, C, Sueur, P,, and Lawens, J,; Contribution to the treatment of fractures of the femur by osteosynthesis, Acta orthop, belg,, 15: 369-75. 1949 34. Bradford, C. H,, Kilfoyle, R. M,, Kelleher, J. J., and Magill, H. K.: Fractures of the lateral tlbial condyle, J. Bone Surg,, 32 A: 39-^7* Jan 1950 35* Pique, J* A,: Bone grafts in fractures of the tlbial tuberosities, Bol, Soc. argent* cir., 10; 695-706, Oct 24, 1949 36. Rochet, P.; Remote result of a partial patellectomy for fracture of the patella, Lyon chlr,, 45; 465-6, May-June 1950 37* Strayer, I. M,, Jr.; Recession of the gastrocnemius; an operation to relieve spastic contracture of the calf muscles, J, Bone Surg,, 32 A; 671-6, July 1950 38, lauge-Eansen, N,; Fractures of the ankle, II, Combined experimental- surgical and experimental-roentgenologic investigations. Arch, Surg,, 60; 957-85, May 1950 39* Wilson, 0, F,; Fractures of the calcaneus, J, Bone Surg., 32 At 59- 70, Jan 1950 40, Geckeler, E, 0.; Comminuted fractures of the os calcls; choice of treatment. Arch, Surg,, 61: 469-76, Sept 1950 41, Michele, A. A,, and Krueger, F, J.; Fractures of the posterior pro- cess of the astragalus. Mil, Surgeon, 106; 130-4, Feb 1950 42, Vecchione, P,: Isolated fracture of the tarsal navicular and the cu- boid, Pollcllnlco, 56: 1386-90, Nov 12, 1949 CHAPTER IX FRACTURE DEFORMITIES By Ernest A. Erav, Colonel, MC Letterman Army Hospital San Francisco, California Assisted By John D, Blair, Colonel, MC I. Consideration of fracture deformities in general A. Review of literature B. Treatment of ‘bowlegs C. Intramedullary nailing II. Bone grafts A, Preservation III. Regional fracture deformities A. Upper extremity B. Trunk C. Hip - arthroplasty I). Hip •• other procedures E. Femur F. Knee Gr. Tihia H. Ankle and foot There are 51 articles abstracted for this chapter. Translations for some of the foreign articles are not available. Consideration of Fracture Deformities in General BARBER (l) continues the review of the literature of 1946 relative to the advancement made in the treatment of serious complicated injuries and diseases of the myoneuroskeletal system. The subjects covered in this sec- tion are early treatment, penicillin therapy, Infected bone defects, osteo- myelitis, upper extremity lesions, injuries to the Jaw, pseudarthrosis of the clavicle and post-traumatic contractures. Bowleg deformities are still being treated by manual osteoclasis. BROCKWAY (2) treated 32 patients between the age of 18 and 24 months with bowleg deformities by the manual osteoclasis method and obtained satisfact- ory to excellent results in all cases. In the treatment of deformities of the joints, LUGIATE (3) writes of the use of Marziani's dentate osteotomy. 132 Intramedullarv nailing of fractures is discussed hy five authors. DELITALA (4) reports the use of a V-shaped intramedullary nail designed to "bridge the gap of a defect in a long hone of the extremities, usually in association with a hone grafting procedure. The nail la inserted at the fracture site and is intended to remain permanently. After Insertion into one fragment, it is driven into the other hy means of a special driver which fits into openings in the nail. Progress is made hy moving the driver through consecutive openings as the nail advances. MACH (5) discusses the sequels of osteosynthesis hy metallic prosthe- ses hy Kuntscher*s method. DUEAO (6) discusses osteosynthesis hy metal re- movable prosthesis. AIMES (?) also writes on the subject of osteosynthesis. MAKHLOUP (8) briefly reviews medical and surgical treatment of pseud- arthrosis. He mentions the limitations and feels that the medullary nailing of Kuntscher is the best method. He cites three of his cases with excellent results. Bone Crafts Preservation of hone transplants and their use in surgery is the sub- ject of a paper hy SICAED and BIN El1 (9)» A total of 205 frozen homogenous hone grafts have been used hy the authors with seven infections (3 per cent) and only three operative failures. In 100 autogenous fresh grafting pro- cedures under similar circumstances there were five cases of suppuration and one loss of the hone graft. The authors conclude that hank hone (frozen and homogenous) is well tolerated and that the behavior of this hone radlologi- cally, clinically, and physiologically is the same as that of fresh auto- genous hone. REYNOLDS and OLIVER (10) "believe that no elements of an autogenous bone graft survive or retain osteogenetic powers. Fixation and replacement of both autogenous and homogenous bone are accomplished by appositional growth of bone from the host. "Creeping substitution" is a localized phase of this process. Although the earlier phases of bone healing are slightly more rapid and uniform with autogenous bone, at the end of ten weeks, there was no microscopic difference between the two types of grafts and complete replacement was present in both. Merthiolate preserved bone and frozen bone were indistinguishable experimentally. VELASCO (ll) reports a series of 128 operations with the use of pre- served homologous hone. There were only 11 failures (8,6 per cent) and the author feels that the healing of hank hone grafts is similar and equally as effective as autogenous grafts. A paper published hy HORVITZ (12) in in Surgery, Gynecology, and Obstetrics on the fate of grafted hone is translated into Spanish. LeCOCQ et al (13) report the results of a series of hone grafting pro- cedures with the use of frozen homogenous hone. There was an infection rate of four per cent in the patients so treated. An end-result study of 56 cases indicates failures in only per cent of the patients and all fail- ures were in attempts to produce lumbosacral fusion. 133 JAMES (14) writes a short article for nurses on the hone hank. Grafting of homogenous hone and cartilage is discussed hy CHRISTIE (15). The history of use of hone and cartilage grafts and hone and carti- lage hanks is reviewed. Nine cases of hone graft utilizing a hone hank in which hone is preserved in penicillin sulfathizole solution are presented. A good bibliography is listed. HANCOX (16) describes how chick embryo hone was grafted to the chorio- allantoic membrane of other embryos, and the results were observed both vis- ually and photographically. Bone trabeculae appeared within three days and the grafts were healed within five to seven days. It seemed apparent that the vascular pattern in the membrane determined the pattern of the trabec- ulae. The author notes that this hone healing occurred in the absence of a nerve supply, there being none in this membrane. The findings suggest that further, more extensive, studies may demonstrate conclusively that the dep- osition of trabeculae is independent of nerve supply and dependent on vas- cular pattern. TOUMEY (1?) reviews cases in which hone grafting operations were performed. 75 per cent of these were compound fractures and 63 per cent were caused by perforating enemy missiles. In from one to two weeks after the wounds had healed, the patient was considered ready for grafting. In the repair of non-union in the shafts of long hones, the grafts were taken from the tihia in 71 cases, and from the ilium in only three cases. The types of grafts employed were: tihial onlay, 55? tihial inlay, 11; intra- medullary, 5? and iliac, 3. In the femur six cases were repaired with on- lay graft and metal plates, the grafts being placed on the lateral aspect of the femoral shaft, and the plates being placed on the anterior surface of the shaft. Tourney stresses the necessity of a tourniquet, even if a Stein- man pin has to he driven into the greater trochanter to hold it up. Patients were immobilized in a double plaster spica for 12 weeks and then fitted with a caliper brace. Tourney suggests the posterior lateral approach to decrease knee stiffness. Union took place in all six cases. In the tibia there were 11 cases with onlay grafts and plates with three failures with non-union and osteomyelitis. The author strongly advises the use of lateral and posterior surface of the tibia for the graft and plate. For the humerus double onlay grafts with multiple chips and plaster spica for three months was the tech- nique used. He stresses necessity of changing the spica at time of suture removal. There were 15 cases with four failures. In the forearm there were four failures out of 25 cases. The author points out the necessity of plac- ing grafts so as to not interfer with pronation and supination and further points out that the lower ulna shaft is not necessary for good wrist func- tion, and resection of the lower ulnar fragment instead of grafting may be carried out. In the hand and foot there were 11 cases with 100 per cent union. Two cases of grafting of the clavicle were failures. KEITH (18) writes on the science of grafting, and FARINA (19) discus- ses the principles of hone grafts. Three cases of autogenous cartilage grafting procedures performed in growing children are described by DUPERTUIS (20). These patients were again observed at periods of four, five, and six years following surgery and in each case it was found that the cartilage had grown approximately 0.6 centi- 134 meters. The author concludes that use of growing autogenous cartilage grafts for the correction of contour deformities in children will encourage earlier restorations which may well bo permanent. The history of the use of transplanted homogenous bone is reviewed by HARMON (21). The author used homogenous bone preserved in a deep freeze or refrigerated in a solution of aqueous raerthiolate in 131 cases. No bone was preserved longer than three months. Four of the author's cases are described and illustrated. The advantages and disadvantages of homogenous bank bone are discussed. In his series there was an infection rate of 3*8 per cent as compared to no infection in 103 cases of autogenous grafts over the same per- iod. The author feels the advantages of bank bone lie in its use to lessen the trauma of surgery and shorten hospitalization time where needed and in its use in spinal fusion where large quantities of bone are required, HERBERT and PAILLOT (22) report their experiences with 60 cases of frozen homogenous bone grafts used in orthopedic procedures. They maintain that these bone bank grafts behave exactly the same as autogenous bone grafts both radiologically and by sections taken at the time of re-operation in three cases. Proof of the vitality of such grafts is demonstrated by their ability to heal when postoperative fracture of the graft has occurred, BOHLER (23) describes the use of bank bone in the bridging of bone de- fects in 99 patients. The advantages of having such bone available for use in extensive bone replacement are discussed. The end results are not avail- able as yet. SICARD and BIN1E! (24) report their results in a series of 203 bone grafts using frozen homogenous bone. In the entire group there were seven infections, with all others going on to primary healing and bone union. The seven infections were in cases of lumbosacral fusion. The conclusion is that frozen homogenous bone is equally as effective as autogenous bone grafts. CLYBOURNE (25) gives a brief review of the principles of bone grafting. HYATT (26) reviews some of the literature on preservation of bone with emphasis on refrigeration of bone at -15° and the effects of refrigeration on bacteria and malignancy. He also reviews the mechanics of the merthio- late bone bank and feels that the use of frozen bone grafts is of noteworthy value with decreased operation time and less postoperative pain. Regional Fracture Deformities In discussing the upper extremity. MARTIN and GERMAIN (2?) give a short report on the treatment of pseudarthrosis. SIFPRE (28) reports a patient who developed late ulnar palsy following resection of the radial head for an irreducible dislocation occurring as part of a Monteggia fracture. SICARD (29) describes a case of fracture of the shaft of the humerus which was treated by open reduction and plating. Three months later the pa- tient developed signs and symptoms of radial nerve weakness and at five months paralysis was complete. X-rays revealed a bony tunnel surrounding the involved nerve. This tunnel was removed at surgery and membranous tis- sue placed around the nerve. 18 months later there was excellent recovery 155 of nerve function. Treatment of neglected dislocation of the distal radiolunar Joint is discussed hy KIRSCH (30). VERBEEE (31) reports his method of fascial arthroplasty of the elbow and the results obtained in a series of six patients. Four results were satisfactory. In one case the range of motion was inadequate and in another there was an unstable elbow joint. Tinder trunk. WAHR0T (32) discusses the etiology of the deformity of the thorax known as "funnel chest." Older methods of correction are described and a case treated by rib resection and sternal elevation is reported. A tibial bone graft was placed transversely behind the sternum to maintain the correction. A technique for spinal fusion utilizing multiple small bone grafts (homogenous) from a refrigerated bone bank is described by TOUMET (33)* He states that the use of refrigerated bank bone has definite advantages over the use of autogenous bone obtained at the time of operation. TROUCHET (34) reports his very satisfactory end results in a series of 20 spinal fusions by the Wilson technique with the combined use of bone grafts and metal plates. JUDET and JUDET (35) report the use of an acrylic prosthesis in con— Junction with lumbosacral bone grafting. The prosthesis is fixed to the low*- er lumbar spinous processes and to the posterior iliac wings. This elimin- ates the lateral and rotary movements which the authors feel are not pre- vented by the H type of lumbosacral grafts and the percentage of postopera- tive pseudarthrosis is thereby decreased. Treatment of moderate pelvic deformities is discussed by CLI7I0 (36). 30N0LA (37) reports a simple case of a vltalllum mold arthroplasty of the hip. Operative technique is briefly described. BURKLE de la CAMP (38) discusses various methods of arthroplasty in a series of 184 cases involving the elbow, hip and knee joints. Good results were obtained in 99 patients with some improvement in 71 others. HEPP (39) presents in detail the indications, operative technique, complications, and end results of a large series of vitallium cup hip arthro- plasties. The results are divided into groups as to type of pathology and degree of operative improvement. CHAPCHAL (40) feels that his three year end results in 45 vitallium cup arthroplasties show that the operation is well worthwhile, although the series is too small and the follow-up too short for a definite conclusion to be of true value. In considering other procedures of the hip, boring of the femoral neck in coxarthrosis deformans is discussed by HUWTLER (4l) in a brief article. 156 STRACKER (42) describes the various etiologic and pathologic varltles of hip joint disease, dividing them primarily into types with normal conflg- oration and types with distortion of the hip joint. Methods of treatment including the use of plastic hip prostheses are briefly discussed. STONE (43) discusses the method of fixation of high femoral osteotom- ies by means of a vitalliom plate. This requires no special equipment or roentgenologic control. Early ambulation with crutches is possible in most cases in less than four weeks. BBLENGER and YANDER (44) have studied a series of 104 cases of frac- tures of the shaft of the femur and have investigated the ensuing complica- tions. Eight cases were treated by open reduction and ordinary fixation. Three had Kuntscher nails inserted. Complications included; pain, persis- tent knee swelling, equinus deformity, shortening, external rotation deform- ity, limitation of knee motion, atrophy and edema. It is concluded that properly applied traction suspension is in most cases the most satisfactory treatment in keeping complications at a minimum. In discussing the femur. McCARROLL (45), after recognizing the more recent trends in equalizing leg lengths by arresting or retarding epiphyseal growth, describes, with brief technical details, the procedures used by ear- lier workers in performing femoral lengthenings. He then describes in great- er detail the various technical procedures used by Dr. Leroy C, Abbott in the first 26 of the 37 such femoral lengthenings performed at the St. Louis Unit of the Shriners Hospital. The various faults and complications of the procedures attempted are outlined , lack of control of the osteotomized fragment ends proving to be the most consistent major problem. This analy- sis and his own experience developed a procedure which he describes whereby a blade plate, inserted into the femoral neck, controls the fragment ends following the osteotomy. The shaft of the blade plate is slotted for its entire length, and this slot is placed over two screws inserted into the proximal end of the distal fragment. In summary, the author states that "the operation for femoral lengthening is a serious undertaking" and outlines strict prerequisites for indication of the procedure. He states that the "complications are so numerous and the prerequisites are so exacting that few patients can be classified as suitable for this procedure.". BRUCKE and MOSER (46) describe a fork-shaped osteotomy procedure which is designed to provide stability and impaction when applied to the correction of femoral deformities. One report on arthrodesis of the knee is given by SARROSTE (4?) who gives his results in 22 patients treated by a cruciate bone grafting pro- cedure. The grafts are obtained from the region of the greater trochanter. Of 21 patients who have had a long enough postoperative course for evalua- tion, all have had successful fusions, without complication. Fusion oc- curred in from four to six months. Bridging tibial defects is the subject treated by two authors, one of whom, MILCH (48), describes and illustrates an operation and presents a case history of the same. Essentially, the operation consists of turning later- ally upon the interosseous membrane anterolateral longitudinally quadrants of the two tibial fragments with periosteum attached. A longitudinal antero— 157 medial section of fibula is then removed and is used in conjunction with iliac hone to create a lattice between the two exposed marrow cavities for the establishment of a synostosis between the tibial fragments and the fib- ula. Milch feels this procedure affords a supplemental method of treatment of tibial defects, finding its best use in large defects involving the mid- dle third of a tibia in which repeated grafting has failed. It has the ad- vantages that the extensive area of bony contact produces a greater likeli- hood of a solid union; it is a one stage operation. The uncut portion of fibula is an excellent stabilizing factor and is still available for future procedures in the event of failure of this procedure. The results of treatment of osteomyelitis and nonunion of tibia frac- tures due to war wounds by sliding tibial grafts are presented by WALLACE (49). These operations resulted in postoperative infection in 13 but with eventual bone and wound healing in all but two cases. The author concludes that this method is superior to other types of bone grafting methods which require use of internal metallic fixation, more overloading of tissues, and more extensive surgery. In fracture deformities of the foot and ankle VAN de VOOREE et al (50) discuss the complications of ankle fractures and review the treatment by means of physical therapy, operative correction, bone grafting and arthrode- sis. MDER (51) believes that, in severe fractures of the calcaneus with depression of a large fragment and interruption of the subastragalar joint surface, elevation of the fragment with filling in of the space by some graft is the treatment of choice. 139 BIBLIOGRAPHY 1. Barter, C. G.: Fracture deformities, Arch. Surg., 59: 1362-70, Bee 19^9 2. Brockway, A.: Manual osteoclasis for treatment of bowleg deformities. West. J. Surg., 58: 221-3, May 1950 3. Lugiato, P.: Marziani's dentate osteotomy in the treatment of deform- ities of the joints, Arch, ortop., 63: 90-4, Jan-Mar 1950 4. Delitala, F.; Permanent medullary nail for treatment of pseudarthro- sis, Zschr. Orthop., 79: 559-70, 1950 5* Mach, F.l Sequels of osteosynthesis hy metallic prostheses by Zunt- scher’s method, Rozhl. chir., 29: 217-28, 1950 6. Burao, A.: An osteosynthesis by metal with removable prosthesis, Gaz. med. port., J: 409-11. Apr-Jun 1950 7. Aimes, A.: Dangers in osteosyntheses, Concours med,, 72: 1965-6, 1? June 1950 8. Makhlouf, A,: Pseud arthrosis and medullary nailing, Bull, actual, med., Beirut, 2: 22-31, Oct 1949 9. Sicard, A., sad Binet, J.: Preservation of bone transplants and their use in surgery, Presse med., 58: 433-4, Apr 22, 1950 10. Reynolds, F. C., and Oliver, B, P.: Experimental evaluation of homo- genous bone grafts, J. Bone Surg., 32 A: 283-97. Apr 1950 11. Velasco, Zimbron A.: Bone banks; homologous bone grafts; study of 128 cases, Mem, Acad, chir.. Par., 76: 619-23. May 31-June 7, 1950 12. Eorwltz, T.; Fate of grafted bones, Dia med., B, Air., 21: 2432-7, Oct 17. 1949 13. LeCocq, J. F,, LeCocq, E. A., and Anderson, Z, J.: Preliminary report on the use of bone bank bone, Surg, Gyn. Obst., 91: 277-80, Sept 1950 14. Janes, J. I, P.s The bone bank, Furs. Mirror, 91: 371-2, Aug 25. 1950 15. Christie, H. Z.: Grafting of homogenous bone and cartilage. Austral. F. Zeal. J. Surg., 19: 320-34, May 1950 16. , Hancox, F, M,: Healing of artificial defects in embryonic bone grafts, J, Physiol., Lond., 109: 131-3. Aug 1949 17. Tourney, J. W.: Experiences with bone graft surgery in the naval ser- vice, U. S. Fav. M. Bull., 49: 1056-66, Fov-Dec 1949 18. Zeith, A.: The science of grafting, Ann. R. Coll. Surgeons England, 139 Lend., 6: 442-5, June 1950 19* Farina, R.: Bone grafts; repair of losses of substance of bone and cartilage; principles, Hospital, Rio, 38: 259-75* Aug 1950 20. Dupertuis, S. M.: Growth of young human autogenous cartilage grafts. Plastic & Reconstr. Surg., $•, 486-93* June 1950 21. Harmon, P. H,; Experiences with use of a bone bank in 131 cases. Per- manent© Pound. M, Bull., Oakland, 8: 97-106, July 1950 22. Herbert, J. J., and Paillot, J.: Bone grafts preserved by refrigera- tion; results and indications, Mem. .Acad, chir., Par., 76: 372-6, Mar 8-15, 1950 23. Bohler, J.: Bone bank of the Vienna Emergency Hospital, Wien. klin. Wschr., 62; 390-1, June 2, 1950 24. Sicard, A., and Binet, J. P.: Homogenous preserved bone grafts, Mem. Acad, chir. Par., 76: 274-80, Jan 25-?eb 1, 1950 25* Clybourne, H. E.: Bone grafting principles, J. Am. Osteopath, Ass., 49: 213-5, Dec 1949 26. Hyatt, G. W,! Fundamentals in the use and preservation of homogenous bone, U, S. Armed Forces M. J,, Is 841-52, Aug 1950 27* Martin, E., and Germain, J.: Treatment of pseudarthrosie, Maroc med,, 28: 625-8, Oct 1949 28, Siffre, J.: Delayed ulnar paralysis following resection of the radial head for an irreducible Monteggia’e fracture, Toulouse med., 51J 265~ 7, May 1950 29» Sicard, A.: Secondary radial paralysis due to inclusion of the nerve in a callus of the humerus, Mem. Acad, chir., Par., 76; 57* Jan 11, 18. 19, 1950 30. Eirsch, J.: Treatment of neglected dislocation of the distal radio- lunar joint, Chirurg, 21: 407-9* June 1950 31. Verbeek, A. D, J.: Arthroplasty in stiff elbow joints, Arch. chir. neerl., 2: 70-80, 1950 32. Wahren, H,; The use of a tibial graft as a retrosternal support in funnel chest surgery, Acta chir. scand., 99s 568-71, 1950 33. Tourney, J.: The simplification of spine fusion technic by use of bone bank, Lahey Clin, Bull., 6: 162-6, Oct 1949 34. Trouchet, P.: Spinal arthrodesis using the Wilson technic, Lyon chir., 45: 575-82, July 1950 35* Judet, R., and Judet, J.: Vertebral immobilization by endoprosthesis 140 with grafting. Press© med,, 58: 579, May 20, 1950 36. Clivio, I.: Treatment of moderate pelvic deformities, Rlv, ostet., 32: 113-6, Mar 1950 37* Bonola, A*: Arthroplasty of the hip with interposition of a vitallium cup; indications and operative technic. Arch, ortop., 63s 132-4, Apr- Jun 1950 38. Burkle de la Camp, E,; Restoration of movement in rigid joints, Arch. Flin. Chir. (langenbeck*s), 264: 455-78, Apr 11, 1950 39* Hepp, 0.; Technic, Indications and prognosis in Smith-Petersen1s cup arthroplasty of the hip, Zschr. Orthop., 79s 433-54, 1950 40. Chapchal, G,: Experience with vitallium cup arthroplasty of the hip, Zschr. Orthop., 79: 417-32, 1950 41. Huwyler, J.; Boring of the femoral neck in coxarthrosis deformans; results and indications, Zschr. Orthop., 79: 454-9, 1950 42. Stracker, 0.: Arthrosis of the hip joint, Zschr. Orthop., 79: 400- 13, 1950 43* Stone, M. A.; High femoral osteotomy with internal fixation. Arch. Hosp. univ. Garcia, Eahana, 2: 131-42, Mar-Apr 1950 44. Belenger, M., and Vander Elst, E,: Complications of fractures of the shaft of the femur, Acta orthop. belg., 15: 297-317, Oct 1949 45. McCarroll, H, R,: Trials and tribulations in attempted femoral length- ening, J. Bone Surg., 32 A» 132-42, Jan 1950 46. Brucke, E,, and Moser, H.: A forked-shaped osteotomy procedure; a new method for correcting deformities of the femur, Eelvet. chir. acta., 16: 365-71, Dec 1949 47. Sarroste, J.: Cruciform arthrodesis of the knee, Toulouse med,, 51: 260-4, May 1950 48. Milch, H.: Tibiofibular synostosis for nonunion of the tibia, Surgery, 27: 770-9, May 1950 49. Wallace, P.; Treatment of fractures with longstanding osteomyelitis; results of use of the tibial sliding graft. Arch. Surg., 61; 379-86, Aug 1950 50. Van de Voorde, C,, De Wulf, A., and Vereecken, E,: Treatment of the sequelae of ankle injuries, Acta orthop. belg., 16: 413-32, July 1950 51. Ender, J.: Bone-implant lining in calcaneal fractures, Wien. med. Wschr., 100: 267-70, Apr 22, 1950 141 CHAPTER X TUMORS OF BONE AM) SOFT TISSUES By Edwin V. Hakala, Colonel,- M.C. U* S, Army Hospital Fort Banning* Georgia I. Considerations of tumors in general A. General B. Sclentifio II* Benign "bone tumors A* Retlculo-endothelial and lipoid types B* Fibrous type C* Osseous type D, Giant cell tumors S. Miscellaneous benign lesions F* Malignant degeneration III* Malignant tumors A, Primary bone lesions B, Myeloma C* Metastatic malignancies Seventywfour articles are abstracted for this chapter* and they re- present an extensive coverage of the many facets of the tumor problem. Considerations of Tumors in General General discussions of tumors include a review by MEYBRDING et al (l) of many articles on tumors of bone and synovial membranes published for "Progress of Orthopedic Surgery for • In the surgical consideration of intraspinal tumors, ADSON (2) empha- sizes early diagnosis since about 80$ of intraspinal lesions are removable* Recovery can often be expected if operation is carried out before irrepar- able cord damage has been done* Tumors of the meninges, nerve roots, blood vessels, and supporting tissues outnumber those originating within the spinal cord by a ratio of four to one* A review of intraspinal tumors at the Mayo Clinic shows 29$ to be neurofibromas, 25$ meningiomas, hemangioendotheliomas, 6$ ependymomas, 10$ sarcomas, chordomas, and 11*5$ intramedullary lesions* Chordomas are primary malignant tumors, but due to slow growth and accompanying pain, surgery is frequently Justified* In such instances, radical removal should be attempted followed by roentgen therapy. Bone lesions producing cord pressure are discussed briefly. 142 An analysis of the twenty-two primary neoplasms of the cranial oones (l.*$) of 1518 primary neoplasms of hone seen at Memorial Hospital in New York from 1926 to 19*+8 is presented hy VANDENBERG and COLEY (3)* They state that fifteen were henlgn and seven were malignant* The authors admit that, due to their recording system requirements, the incidence of henlgn tumors is prohahly too low. Giant cell tumor is rare; It may he treated hy roentgen therapy* Sarcoma has an extremely unfavorable outlook because, owing to its location, it does not lend itself to radical surgery* Myeloma of the skull is usually a manifestation of widespread disease* In the so-called "solitary" lesions, however, roentgen therapy may he of value. Numerous articles of sclentific interest are contributed which deal with the various aspects of tumors in general. The diagnosis of hone tumors is discussed hy BRAILSFORD (4). The clinical findings must he taken into consideration along with x-ray changes. The lag in development and persistence of x-ray changes sometimes do not correspond to the physical condition of the patient. Biopsy is condemned. (Ed? The author stresses perhaps a little too much the dangers of biopsy and the Inconclusiveness of the pathologist. It is to he remembered that anyone dealing with hone tumors should he thoroughly familiar with the clinical findings, x—ray manifestations, and gross and microscopic appearances of hone lesions. If considered alone, x-ray, clinical, chd pathological interpretations can all he faulty, and a conclusion should not he based on the evidence of my one entity to the exclusion of the others.) In a study of transplantable tumors, CRAIGIE (5) shows that serial passage of tumor is possible only in the species and genetic constitution in which it arises. A quantitative study as to amount, preparation, and manner of transfer is necessary in order to help elucidate the relation of virus to cancer. To crystallize their findings ina lengthy study of the production of malignancy in vitro, EARLE et al (6) present a chart which correlates more closely the chronological relationships of the various studies presented and the relationship of the various cell strains and subordinate lines studies. This series of investigations has been in progress for more than eight years. There are no data from these studies that warrant considering the changes in the presumably untreated D control strain as essentially different, except in degree, from those shown hy the cell strains deliberately treated with carcinogen. EOLETSKY et al (?) report the production of malignant tumors in rats with radioactive phosphorus. He reports the development of thirteen tumors following injection with radioactive phosphorus, of which ten were osteogenic sarcomas. Atypical hone proliferation is seen in those developing malignancy. The incidence of malignancy in rats injected is given as GROLLMAN (8), WALTON (9), GILES (10) and CARO (ll) review the use of radioactive drugs and radiation therapy for malignancy. LAYTON (12) discusses the efficacy of labeled inorganic sulfate in the diagnosis of cartilaginous tumors and their metastases. He relates that muscle and tumor tissue taken from six patients with diagnoses of osteo- cartilaginous tumors were incubated in a sodium sulfate solution labeled with radioactive sulfur. The sulfur, he states, was then precipitated out with barium chloride and the radioactivity was measured to determine uptake* The author reports that cartilage takes up a largo amount, while other typos of tissue absorb much less, thus supporting the pathologic diagnosis of cartilage-forming tumor. Experiments on virus interference by serially passed Hodgkin's disease extracts in chicken eggs are described by BOSTICK (13)* A virus etiology has long been suspected in Hodgkin's disease, and this study shows that the amniotic fluid taken from a series of fertile chicken eggs inoculated with Hodgkin's disease tissue extracts reveals virus interference capacities and, thus, a difference from other tissue extracts. This factor Is reported to have been encountered in all Hodgkin's disease extracts, and it is suggested that there may be some etiologic significance. GOIDIE and HAHH (1*0 write that studios on mice indicate that immediate morphological changes and sometimes disappearance of free sarcoma tumor cells occur when the peritoneal fluid is treated with radioactive iodine. A control series does not show this change. Data on osteosarcoma induced by beryllium oxide are compiled by DHTEA and LARGrMT (15)* After one year, eight of nine adult rabbits Injected intravenously show evidence of osteosarcoma (six primary, two multiple). Results are proven by microscopic section. There is no evidence that beryllium causes tumor other than by intravenous administration to rabbits. Benign Tumors The reticulo-endothelial and lino id types of tumors are considered by twelve authors. HIXDN and PERRY (16) deserlhe a case of reticuloendo- thelial hyperplasia of hone. STE7MS0N (17) discusses xanthoma and giant cell tumor of the hand. Giant cell tumor is a firm, fixed, benign, nodular tumor arising from firm skeletal tissue. It is usually solitary and occurs on extremities. Recurrence is commonly due to incomplete excision. He feels that xanthoma is a mani- festation of metabolic fault and is usually multiple and symmetrical. Microscopically they resemble each other. Pseudocystic disease of bone is suggested by JACOBSOH (18) as a term to include eosinophilic granuloma, lipid granulomatosis, and fibrous dysplasia* The Interrelationship of these three lesions is discussed* Pour cases sure reported to demonstrate the similarity. Histiocytic granuloma of the skull, a trl-phasic clinic©pathologic syndrome previously termed Letterer-Siwe's disease. Hand—Schuller-Chrlst Ian's disease, and eosinophilic granuloma, is the subject of an article by GOODHILL (19)* All throe are probably different phases of the same disease* Eighteen cases are reported. The basic disease processes are dysplasia 144 and hyperplasia of the reticulo—endothelial system. The terra "histiocytic granuloma" Is proposed to include all three phases. HANSM (20) presents fire cases to demonstrate the relationship of Hand»Schaller«-Chr 1st lan’s disease* Letterer-*Slve* s disease, and eosinophilic granuloma of bone. He, like Ooodhill, contends that these are all phases of the same disease. Vhat determines the phase is unknown unless it is the age of the patient at onset. WMTHOLD and HADDERS (21) also discuss this subject. According to BUCY AND (22) Intradural spinal granulomas are rare 1 esions and are usually associated with Pott's disease. However, any agent causing a granulomatous reaction can cause such an entity without extradural or hone involvement, A case is presented of a granuloma around the spinal cord in the region of T—7 of tuberculous nature which caused pressure symptoms and spinal fluid block. The patient continues to be well three years after laminectomy and removal of the granuloma. JOHNSON (23) reviews literature on thirty-six cases of intramedullary lipoma of the spinal cord and reports one case. The diagnosis is made by neurological symptoms. COLLINS and HENDERSON (2*0 report another case in a forty-year-old male with recent complete paraplegia and a twenty—year history of transient paraplegia. X-ray shows only a kyphosis. Most of the articles on fibrous types of tumors are concerned with fibrous dysplasia of bone. A complete study of seven cases of this disease and follow-up reports on six of these is given by PROFITT et al (25). Ho one type of clinical examination will differentiate this from bone cysts and giant cell tumors, but proper interpretation of clinical, laboratory, roentgenologic, operative, and pathologic findings will differentiate be- tween this and other diseases of bone. In most instances of multiple bone involvement by fibrous dysplasia, the diagnosis can be made by x—ray and the calcium and phosphorus levels. Healing follows fracture, as in simple bone cysts. In long bones, healing with new bone formation follows curett- age. In a rib lesion with pain, the intercostal nerve should be excised with the rib. Fibrous dysplasia of bone Includes monostotic and polystotic lesions as well as Albright's syndrome according to RUSSELL and CHANDLER (26). Basic morphology includes replacement of cortical and cancellous bone and marrow with fibrous connective tissue containing varying amounts of imperfect cancellous bone. Etiology and pathogenis are still obscure. Biopsy is often necessary to make a diagnosis. Treatment consists of treating fractures, correcting deformities, and excising painful lesions when possible. 7ALLS et al (2?) state that the term, "fibrous dysplasia" cannot be applied with certainty to solitary lesions. Ho relationship is established between fibrous dysplasia and neurofibromatosis. He feels that solitary lesiens are more often the final cicatrical stages of processes (inflammatory, metabolic, and traumatic) rather than dysplastlc stages. PERRY and HAD HI (28) report four oases of fibrous dysplasia of bone and opine that the disease is more common than is realized. 145 A case of polystotic fibrous dysplasia, Albright's disease, is reported hy HACKBTT and CHRISTOPRERSON (29) because of the unusually early manifestations of sexual precocity in a five—year—old girl whose menses started on her second day of life. The total pathologic picture of neurofibromatosis (von Reckling- hausen's disease of the nervous system) is analyzed hy LICHTENSTEIN (30). The basic lesions in neurofibromatosis are foci of hyperplasia and neo- plasia of supportive derivatives of the ectoderm, sometimes with involve- ment of vascular and parenchymatous elements. The term "neurofibromatosis " or von Recklinghausen's disease of the nervous system, is used to differen- tiate this entity from the other, unrelated von Recklinghausen'e cystic disease of bone. This condition is characterized by pigmented areas of skin, nerve tumors, and fibrocystic bone disease. A working classifica- tion of this varied disease is given. In the classical form, cutaneous lesions and tumors in the central and peripheral nervous systems appear with or without bony lesions. A central form exists with no superficial evidence of the disease, and this type has associated acoustic neurinomas, meningiomas, optic nerve gliomas, and spongioblastomas. The abortive type includes isolated ca:*e au lait patches, pigmented dermofibromatosls, and hypertrophy of portions of the body, A defective germ plasm seems at fault In the disease since most cases are congenital and heredo- familial. A review of neurofibromatosis is given by FAIRBANKS (31)* The nature of the pathological bone changes remain obscure. A neurogenic origin of the subperiosteal lesion is acceptable, but the author does not feel this to be the case with endosteal lesions. Neurofibromatous tissue may or may not be found at the site of pseudarthrosls. A case of Intraspinal neurofibroma is reported by BUCHAN (32) showing widening of pedicles and erosion of bodies of T-12 and L-l Another case of spinal neurofibroma is reported by SCHENKEN (33)* There are several articles which deal with tumors of osseous types. Osteoid-osteoma and its etiologic, pathologic, and clinical factors are reviewed by CHANDLER and KAELL (3*0# Seven cases are presented, including one with vasomotor changes (increased sweating and a local rise in temperas ture). These changes are probably due to stimulation of sympathetic fibers near the nidus. Pain in osteoid-osteoma may be referred, Laminagrams may be of value in localizing the lesion. Three cases of osteoma of the skull are presented by MEREDITH (35) who reports successful surgical removal of the hony masses. Two varieties are illustrated in that two of the cases are of a diffuse nature involving the frontal bone, and the other is a discreet, welLniefined, dense mass in the temporal bone. The latter presents a greater technical difficulty in removal. The exact nature or etiology is not given. Symptoms are due to pressure from the location of the tumor mass. ROBINSON and SPENCER (36) give an account of a sixty-five—year-old woman with a cancellous osteoma (heterotopic ossification) in the right breast. They state that, following a radical mastectomy, pathological 146 examination revealed cancellous bone in the small, hard mass with haemopoietic elements and chronic mastitis. Two cases of osteoclastoma associated with generalized bone disease are described by HILTON (37), one associated with osteitis deformans and the other with osteitis fibrosa cystica* It is reported that sections were typical of osteoclastoma and neither case responded to x-ray therapy. Of benign chondro-osteoblastoma, COPPLLO (38) says that this tumor usually appears in the dlaphyses of individuals between the ages of fifteen and forty. It is more common in women. Secondary malignant changes are possible, and lesions are both multiple and single, The condition is radio- resistant; recommended treatment is conservative surgical removal, Diag*» nosis is important in order to avoid radical, unjustified amputation. The author apparently refers to Codman's tumor (benign chondroblastoma of the epiphyseal-line area), CORNIL et al (39) report four cases of osseous tumors developing in Paget's disease. They report that none died of metastases. In two cases, the tumors are classified as benign "histiocytomas"; in the third case, as multiple tumors, one being benign and another a malignant reticulosarcoma; and the fourth case, as a malignant reticulosarcoma. The authors theorize on pathogenesis, feeling that both the basic disease process and the tumor development are end products of abnormal activity in the "reticulohistio- cytic elements". The report of a case of Hodgkin's disease with osseous lesions and slight lymph node involvement is offered by SUAREZ FDPO (40). In 130 cases of giant cell tumors of bone diagnosed at Mayo Clinic from 1916 to 1947 by means of biopsy, MNTBHDING- and JACKSON (4l) report that seven cases occurred in which the bones of the hands and feet were involved. One case is seen in the finger and six in the foot. These locations, the authors feel, are rare sites for tumors of this type. Microscopic confirmation is necessary for accurate diagnosis. Prom one case of their own and a survey of the literature on nine others, RUCKLESS and LAWLESS (42) conclude that giant cell tumor of the ribs is a slow growing, benign tumor, but it may become malignant. Treat- ment of choice is surgical resection. Irradiation may be used, and the prognosis is excellent, LEVINTHAL and KEAPT (43) review current opinion of radiologists and surgeons concerning proper treatment of benign giant cell tumor. No unanimity of opinion is seen as to the superiority of surgery, irradia- tion, or a combination of the two. The authors report ten cases treated by curettage, aspiration, and primary excision or resection, followed by immediate reconstructive surgery. They feel that this technique has the following advantages; (a) more definite and time-saving end results and (b) immediate cessation of the destructive process, diminishing the extent of necessary reconstruction in direct proportion to the time elapsing since onset. No definite statements concerning follow-up on these ten cases of 147 benign lytic bone tumors are given, A case of giant cell tumor confined to the greater trochanter is reported by STEWART and JAMES (MO which was thought preoperatlvely to be tuberculosis. No others are reported in the literature, HOWELLS and FRIEDMAN (45) find giant cell granuloma associated with lesions resembling polyarteritis nodosa. Among miscellaneous benign lesions, unicameral bone cyst is frequently seen. One case is reported by HOTTER (46) because it extended across the epiphyseal plate into the epiphysis through a 2 cm, defect in the plate and did not Involve the edge of the plate. The author states that curettage and filling with bone chips did not result in growth arrest. Gaucher's disease in bone is well-discussed by ETJLCWSEI (4?), He states that osseous manifestations occur "not infrequently1*, and they add an important diagnostic criterion to the better known clinical signs and symptoms of this disease. Bone lesions may be considered as primary and secondary. The primary lesion is due to the actual infiltration of the bone marrow by Gaucher's cells. This results in osteolytic areas in the roentgenogram. The secondary changes develop in the opposite direction toward bone condensation, and they are due to aseptic necrosis upon which is superimposed the effects of mechanical stresses and weight bearing. Some of the primary bone lesions apparently heal. One case report is given. Two oases of endometrial tumors in the extremities are reported by DUNCAN and PITNEY (48) in the femoral areaxf the upper thigh. Thirty-five children with acute leukemia treated with arainopterln are presented by KARPINSKI and MARTIN (49), These cases demonstrate the changes in bony evidence of the disease. New lesions may develop during therapy, while others disappear. Heavy transverse bands at the end of long bones are seen to develop during therapy. No specific action on skeletal lesions by aminopterin in acute leukemia can be stated from the authors' observations. Malignant degeneration of benign giant cell tumor of bone is the subject of an article by LEUCUTIA and COON (50), They report seventy*- five cases treated at Harper Hospital, Detroit, from 1923 to 1947* Malignant degeneration is observed in 9$ (seven cases). In four of these, it is seen to occur after routine roentgen therapy; in one, before the series of treatment was completed; in another, following roentgen therqjy of such small dosage that its significance can almost certainly be disregarded (authors' statement); and in one case, " spontaneous ly1*, In this last case mentioned, the diagnosis is reported to have been made after unsuccessful roentgen therapy, hlstiologlcal examination first being possible after amputation since biopsies were refused previously. In two cases of the total seven, degeneration following surgical procedures is shown. How- ever, one of these, treated by three surgical interventions followed by roentgen therapy, is seen to develop osteogenic sarcoma seven years later. 148 In the other, degeneration is reported after curettage and filling with bone chips. The authors conclude that malignant degeneration occurs in 10$ to 15$ of cases as a natural sequence of events and is unaffected by the type of treatment. HERRMANN (51) reports four cases of sarcomatous transformation in patients with clinical and microscopic evidence of multiple neurofibroma- tosis* (von Recklinghausen’s disease). Three are said to have developed sarcomata in their sciatic nerves, and one, a sarcoma retroperitoneally. Patients should be cautioned about the hereditary possibility of trans- mission of the disease and associated congenital abnormalities* diagnosis is simple clinically. Biopsy of cafe au lalt spots or the neurofibromata should not be done because of the possibility of stimulating sarcomatous transformation. The lesions should be widely excised only if there Is sudden swelling associated with pain, and then the operator should be pre- pared to do more radical surgery if the lesion proves to be a sarcoma. Such change is especially apt to occur during puberty or pregnancy. Radical surgery is superior to irradiation or nitrogen mustard as treat- ment, There is wide variation in the sarcomata hlstlologically, even in different sections of one tumor. COOPER (52) reports two cases of chondrosarcomatous deganeratlon of a myositis ossificans and urges early biopsy if diagnosis is in doubt. Malignant Tumors Primary 'bone lesions are of part 1calar Interest and Importance to the orthopedist* An analysis of 205 cases of malignant hone tumors seen at Campbell Clinic since it opened is reported hy PREVO (53)* Of all orthopedic patients seen, 0*8$ have tumors, and more malignant than benign cases are recorded (415 malignant, 287 benign). Analysis of the malignant ones admitted (205) reveals that? (a) five-year survival in Ewing’s sarcoma does not assure freedom from metastasis and (b) In other bone malignancies, favorable results after five years are much more Indicative of permanent cure* The most logical treatment is early amputation followed by irradiation* A classification of the primary types of malignant tumors of the mandible is presented by CONLEY and PACK (54), The various types are classified with respect to size, position, and extension* Pour basic surgical techniques, with Individual modifications are described for the treatment* Six illustrative cases are reported to clarify the analysis and surgical approaches, Fifty-nine cases of osteogenic sarcoma with survival for five years or more are analyzed by COLEY and HARROLD (55)* series includes fibrosarcomas and chondrosarcomas* The prognosis is better in these than in the narrowly-4efined, osteogenic sarcoma* The microscopic picture is the most reliable index as to prognosis* The greatest number of five-year survivals are amputees, with or without supplementary treatment (Coley*s toxins, irradiation, etc*)* The authors have abandoned the use of Coley*s 149 toxins and preoperative irradiation, No five-year survivals In any malignant tumor of the proximal femur are reported, years Is not a long enough period on which to base end results. Lobectomy is recommended for solitary pulmonary metastases in cases of low grade malignancy, authors want to dispel the apathetic attitude that this disease is uniformly fatal and therapy of such little value that no great effort should be made to reach an early diagnosis and institute prompt treatment* Vertebral location for Ewing's tumor, state CARTER and CO?/PTON (56), is noted to be 4,7/6* A, case is presented of the third dorsal vertebra with spinal cord involvement and symptoms. They state that the patient died two years after biopsy and palliative x-ray therapy. Thirty-eight cases of fibrosarcoma of the extremities arereviewed by ZARZECKI (57) who is of the opinion that these lesions should be excised early and followed carefully. If there is recurrence, proven by biopsy, amputation should be done. This series of cases is reported to support this plan of treatment, Extension of primary neoplasms of bone to bone marrow is studied by UPSFAW et al (58) on amputation specimens including fifty cases of osteo- genic sarcoma, twenty cases of Ewing's sarcoma, and five Cases of primary chondrosarcoma. Gross and microscopic studies at the Mayo Clinic are pre- sented. Direct extension is the usual method of spread into the bone marrow from its initial location in a long bone. This may occur without x-ray evidence of its presence. Medullar:;- involvement may extend a con- siderable distance past any gross evidence of such extension. Of these three tumors, Swing's shows the greatest tendency to spread, osteogenic sarcoma the next, and primary chondrosarcoma the least* None of the chondro- sarcomas show spread of more than three inches beyond the cortical involve- ment by the lesion? 45$ of the sarcomas and 20$ of the osteogenic sarcomas do show this degree of spread. The amount of medullary involve- ment is not prognostic in osteogenic sarcoma? in king’s tumor, however it is. If amputation is done through the bone containing the lesion, microscopic examination of the bone marrow at the level of amputation is mandatory to determine whether the amputation is proximal to the lesion. The authors* statistics indicate higher survival rate if the amputation is proximal to the bone containing the lesions than if it is through the in- volved bone. Twenty-one cases of multiple myeloma from the Winnipeg General Hospital are reported by BROWNELL (59)* Pain and weight loss are the most common complaints, Bence-Jones protein is present in approximately lhf$ (3 of eighteen cases studied). This proteinuria is believed transient in nature* The value of sternal marrow aspiration for diagnosis is stressed, BLUEFELD et al (60) report one case of this malady with eraohasls upon the fact that this is a generalized disease, RUSSO and BENDEP (6l) report seventeen cases of multiple myeloma and point out that it is a malignant systemic disease with a grave prognosis. Their findings are consistent with other literature on the subject, A case of multiple myeloma in a man aged ninety-two is reported by PARNES and WILSON (62), 150 In a case of multiple myeloma with new hone formation, XRAININ et al (63) state that the diagnosis was made on the basis of xwray findings, sternal puncture, and the presence of plasma cells in the circulating blood smear. X-rays showed radiating spicules of bone in along bone, and biopsy revealed newly formed bone trabeculae, A slightly elevated alkaline phosphatase and a calcium of 15 mg$ were found. The authors state that no autopsy was done, A case of solitary myeloma of the sacrum is presented by NASSIM and CRAWFORD (64-) in which the patient lived five years after the first detection by roentgenogram. Biopsy, and later autopsy, failed to show any other area of involvement. Proteinuria and a disturbed serum calcium balance are shown, A urinary output of calcium of 188$ of the intake is recorded, and the ratio of urinary calcium to fecal calcium is 0,84:1 as compared to a normal of 0,22:1, On two occasions traces of Bence-Jones protein are recorded, A review of the literature on solitary myeloma is given. Metastatic malignancies are described in several papers, A case of malignant melanoma metastatic to the femoral region with fatal outcome following simple excision, presented at a tumor clinic conference, is recorded in the CANCER BULLETIN OF TEXAS (65). One thousand consecutive autopsled cases of epithelial carcinoma are analyzed by ABRAMS et al (66), The 272 Cases showing bone Involvement are broken down according to the primary sites as follows: 122 of 16? breast (73/0* 75 of 160 lung (47$), 8 of kidney (24$), 11 of 87 rectum (13$), 4 of 32 pancrea s (13$), 13 of 119 stomach (11$), 11 of 118 colon (9$), 6 of 64 ovary (9$). PEARSON and FITZGERALD (67) review 140 cases of carcinoid tumors with sixteen metastatic cases, two being vertebral metastases. Thirty-five proven cases of thyroid cancer metastases in bone are studied from the standpoint of roentgen diagnosis by SHERMAN and I7KER (68) The salient features of this type of tumor are listed, and a basically uniform roentgen appearance is noted. Characteristically, this metastasis in purely osteolytic, resulting in a somewhat unusual feature of "bone destruction in continuity". This means that the metastatic destruction in a bone crosses a joint and extends into other bones. Incomplete, delicate septation, destruction in continuity, medullary origin, oval shape, indistinct borders, and absence of periosteal reaction are the commonest findings in this type of metastasis, A second case of metastatic carcinoma of the femur treated by re- section and bridging bone graft is described in ARCHIVES OF SURGERY (69)* IAVEDAN (70) presents three cases of complete fractures of the femoral neck without trauma in young persons following intensive irradiation of the pelvis for cancer of the uterus. 151 HIDDLEST0N15 (71) reports a case of a patient with a pathologic fracture of the femur secondary to metastasis from carcinoma of the breast. He states, that because of severe pain at the fracture site, treatment with intramuscular testosterone was instituted. Prompt relief of pain is reported, and roentgenograms are said to reveal the formation of dense callus at the previously osteoporotic fracture site. LAFFERTY and PENDERGRASS (72) report two cases of testicular carcinoma with bone metastasis, one of which occurred in a male pseudohermaphrodite and was first discovered when metastatic lesions appeared in various bones. For this reason, the authors recommend that abdominal testes be removed if they cannot be brought into a position where they can be examined easily and frequently. The rarity of bone metastasis in carcinoma of the testicle is stressed, but the facts that pain from these metastatic lesions can be well controlled by irradiation and that these lesions can be sterilized by adequate dosage are brought out. PHILLIPS (73) reports a case of new bone formation associated with direct extension into the pelvis from lymph node metastases in infiltrating carcinoma of the bladder. Primary carcinoma of the nail, a rare tumor, is discussed by RDSSELL who states that only eighteen proven cases have been reported. It is located along the sulcus of the nail, usually follows trauma, and has the gross appearance of carcinoma. It spreads locally and metastasizes late and regionally. Treatment is amputation. 152 BIBLIOGRAPHY 1* Meyerding et alj Tumors of "bone and of synovial membrane, Arch* Surg., 60: 170-81, Jan 1950 . 2* Adson, A, ¥,: Surgical consideration of intrasplnal tumors, J* Tnternat* Coll* Surgeons, 14: 1-11, July 1950 . 3« Vandenherg, Jr*, H, J. and Coley, B. L.: Primary tumors of the cranial hones, Surg, Oyn. Ohst*, 90: 602-12, May 1950 • 4, Brailsford, J. P.: The diagnosis of hone tumors, lancet, Lond*, 2: 973-5. Nov 26. 1949. 5* Craigle, J*: A quantitative approach to the study of transplantable tumours, Brit* M, J,, 2: 1485-91, Pec 31. 1949. 6* Earle, W. p,, Schilling, E, L., and Shelton, E*: Production of malignancy in vitro. Continued description of cells at the glass inter- face of the cultures* J. Fat. 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P.: Effects of radioactive iodine on free sarcoma 37 cells in the peritoneal fluid of the mouse, Proc. Soc. Erp. Biol. F. Y., 74: 634-8, Jul 1950 15, Dutra, F. R. and Largent, E. J., Osteosarcoma induced by beryllium oxide. Am. J. Path., 26: 197-209. Mar 1950. 153 16. Nixon, J. W. and Perry, Jr,, J. P.? Reticuloendothelial hyper- plasia of hone; report of a case of Letterer-Slwe's disease, J. Internal. Coll. Surgeons, 13? 788-90, June 1950. 17. Stevenson, T. W.r Xanthoma and giant cell tumor of the hand, Plastic & Reconstr. Surg., 5? 75-87, Jan 1950. 18. Jacohson, W, N, r Pseudocystic disease of hone. Arch. Int. M., 86; 35-50, Jul 1950. 19. Goodhill, Y.: Histiocytic granuloma of skull; a trl-phaslc clinlco- pathologic syndrome previouslytermed Letterer-Slwe*s disease, Fand- Schuller-Christian1s disease, and eosinophilic granuloma: report of 18 cases, Laryngoscope, 60; 1-54, Jan 1950. 20. Hansen, P. B,: The relationship of disease, Letterer-Siwe's disease and eosinophilic granulomas of hone; with re- port of five eases, Acta radio1., Stockh., 32? 89-112, Pep 30, 1949. 21. Wentholt, E, M. M. & Eadders, H. N.; Nosinophiel granuloom van huld en ekelet en het verhand med de zlekte van Hand-Schuller—Christian en van Aht-Letterer—Siwe, Ned. tschr. geneesk, 93J 3622-9pl» Oct 22, 1949. 22. Bucy, P. C, and Oherhill, F, R.: Intradural spinal granulomas, J. Neurosurg., 7? 1-12, Ulus, Jan 1950. 23* Johnson, D, P,: Intramedullary lipoma of the spinal cord; review of the literature and report of case. Bull. Los Angeles Neur. Soc., 15? 37-42, March 1950. 24. Collins, D. E. and Henderson, W, R,: A case of intradural spinal lipoma, J. Path. Bact., Lond., 61? 227-31 2 pi, Apr 1949. 25. Profltt, J. N., et al; Pl>rous dysplasia of hone, Ann. Surg., 130 ? 881- 895. Nov 1949. 26. Russell, L. W. and Chandler, F. a.: Fibrous dysplasia of hone, J. Bone Surg., 32A; 321-37. Apr 1950 . 27. Vails, J., Polak, H., end Sckajowicr, P. r Plhrous dysplasia of hone, J. Bone Surg., 32A? 311-22, Apr 1950. 28. Perry, S# p. end Haden, Jr., W, D. • Plhrous dypplasia of hone, Guthrie Clin. Bull., 19? 156-64, Jan 1950. 29. Fackett, Jr. L. J. and Christopherson, V, M,? Polyostotic fibrous dysplasia, J. Pediat. S, Louis, 35 * 767-71 illust, Dec 1949. 30. Lichtenstein, B, V,* Neurofibromatosis, von Recklinghausen *s disease of the nervous system; analysis of the total pathologic picture. Arch. Neur. Psychiat., Chic., 62? 822-39. illus, Dec 19*19 • 154 31. Falrbank, E. A, T,r Neurofibromatosis. J. Bone Surg., 32B: 266-70, May 1950. 32. Buchan. J. F,; #Intrasplnal neurofibroma and neurofibroma of neck, Proc. R, Soc., M., Lend.,43: 315, Apr 1950 33* Schenken, J. R.: Spinal neurofibroma, Nebraska M. J., 242? 15^-5, Apr 27, 1950. 34. Chandler, F, A. and Kaell, H, I,? Osteoid—osteoma. Arch. Surg., 60r 294-304, Feb 1950. 35* Meredith, J. M. r Osteoma of the cranial vault and base; three cases illustrating two varieties, South, Surgeon# i£. 785-95, Aug 1950. 36. Robinson, R. H, 0, B. and Spencer, F, A,: Cancellous osteoma in the breast, Brit. J, Surg., 37? 481-2, Apr 1950. 37. Hilton, G,: Osteoclastoma associated with generalized bone disease, Brit. J. Radiol., 23: 437-9, Jul 1950. 38. Copello, 0,: Condro—osteoblastomas benignos, Rev. As. med, argent., 63 : 577-83. 15-30 Dec 1949. 39. Cornil, I. et air Les tumeurs os senses de Paget, Sem. hop.. Par., 26: 2357-61, Jul 2. 1950. 40. Suarez Plipo, J.j Hodgkin's disease with osseous lesions and slight lymph node involvement; report of a case, Hosp. Univ. Garcia, Habana. 41. Meyerding, E, W and Jackson, A, E.: Benign giant cell tumors; a report of 7 cases in which the bones of the hands and feet were in- volved, Surg. Clin. N. America, 30; 1201-13, Au*” 1950. 42. Buckless, M. G, and Lawless, E. .: Giant-cell tumor of ribs; a case report and survey of literature, J. Thorac. 19: 438—43, Mar 1950. 43. Levinthal, D, H. and Kraft. G, L,: Eradication of benign lytic bone tumors and immediate reconstructive surgery with emphasis on benign giant cell tumors, Surg. Gyn. Obst., 89: 734—47, Dec 1949. 44. Stewart, M. J, and James, Jr., 0. E.: Giant-cell tumor confined to the greater trochanter; a case report, J. Bone Surg., 32A: 439-42, Apr 1950. 45. Howells, 0# h# an(i Friedmann, I.r Giant cell granuloma associated with lesions resembling polyarteritis nodosa, J. Clin. Path., 3: 221—9, Au£ 1950. 46. Butter, C. C.: Unicameral bone cyst; report of an unusual case, J. Bone Surg., 32A: 430-2, Apr 1950. 155 47, Kulowski, J.: Gaucher's disease in hone. Am, J, 63? 840—50 June 1950* 48, Duncan, C, and Pitney, W, R,: Endometrial tumours in the extremities, M. J. Australia, 2: 715-7, Nov 12, 1949. 49, Karpinski, Jr,, P, B, and Martin, J, P,: The skeletal lesions of leucemic children treated with amlnopterin, J, Pediat,, S, Louis, 37? 208-23. Aug 1950. 50, Leucutia, T, and Cook, J, C,: Malignant degeneration of henign giant cell tumor of hone, Am, J. Roentg, 62? 685-706, lllust, Nov 1949. 51, Hermann, J,: Sarcomatous transformation in multiple neurofibromatosis (von Recklinghausen's disease) report of four cases, Ann, Surg,, 131? 206-17. Peh 1950. 52, Cooper, Jr., G,: Case reports; chondrosarcomatous degeneration of a myositis ossificans, Virginia M, Month, 77? 306, Jon© 1950, 53* Prevo, S, B,: A clinical analysis of 205 cases of malignant hone tumor, J. Bone Surg, 32A, 298-306, Apr 1950. 54. Conley, J, J, and Pack, G, T,: Surgical treatment of malignant tumors of the inferior alveolus and mandihle. Arch. Otolar,, Chic, 50? Nov 19*49. 55* Coley, B, L, and Harrold,Jr,, C, C.: An analysis of 59 cases of osteogenic sarcoma with survival of 5 years or more, J. Bone Surg., 32A: 307-10, Apr 1950. 56, Carter, E, V, and Compton, J, W,: king's tumor of the vertebrae. South, Surgeon, 16? 796-802, Aug 1950, 57* Zarzeckl, C, A,: Fibrosarcoma of the extremities, a review of 38 cases, North Carolina M. J., 10: 605-7, Nov 1949. 58, Upshaw, J. B, et al? Extension of primary neoplasms of hone to hone marrow, Surg, Gyn, Ohst., 89r 704-14, illus. Dec 194-9. 59* Brownell, E, G.: Multiple myeloma, Canad. M, Ass. J,, 63? 157-63, Aug 1950. 60, Bluefeld, Jr., C,, et al: Multiple myeloma, report of a case, N, J, Med, Society, 47? 426-7. Sept 1950. 61, Russo, P. B. and Bender, H. R,: Multiple myeloma, J. Oklahoma M, Ass. 4-3: 257-60, June 1950. 62, Parnes, I, H. and Wilson, M, J,; Multiple myeloma; a case report of the oldest known patient, N, York State J, M,, 50: 329-30, illus, Peh 1. 1950. 156 63. Fralnin, P., D’anglo, C. J. and Smelin, A.? Multiple myeloma with new hone formation. Arch. Int. M., 84: Dec 1949. 64. Hassim, J. R, and Crawford, T.: Solitary myeloma with generalized metabolic disturbance, Brit. J. Sorg., 37: 287-91, Jan 1950. 65. Tumor clinic conferences? malignant melanoma metastatic to the femoral region, Cancer Bull. Texas, 2t 66-7, May-June 1950. 66. Abrams, H. L., et als Metastases in carcinoma; analysis of 1000 autopsied cases. Cancer, H. T., 3: 74-85, Jan 1950. 67* Pearson, C. M. and Fitzgerald, P. J.: Carcinoid tumors; a re- emphasis of their malignant nature; review of 140 cases, Cancer, H. Y., 2: 1005-26, lllust., Hov 1949. 68. Sherman, R, S, and Irker, M.: The roentgen appearance of thyroid metastases in bone, Am. J. Roentg., 63? 196-203, F«b 1950. 69* Surgical clinics; rarefying lesion of the femur following metastatic carcinoma of the thyroid. Arch. Surg., 60; 1027-33* Way 1950. 70. Lavedan, J,, : Contribution a I1etude dee fractures du col femoral consecutIves au traitement roentgentherapique des cancers uterins. Paris med., 40; 381-5* Jul 15, 1950. 71. Hiddlestone, H, J. H.J Healing of a pathological fracture by hormone therapy, N. Zealand M. J., 49: 146-7, April 1950. 72. Lafferty, J. 0, and Pendergrass, 5.P.: Carcinoma of the testicle with metastasis to bone? report of two cases, one in a pseudoherma- phrodite, Am. J. Roentg., 63: 95-101, Jan 1950. 73* Phillips, J. M.: Hew bone formation associated with direct extension from lymph node metastases to bone in infiltrating carcinoma of the bladder, Radiology, 55s 94—6, Jul 1950. 74. Russell, L. V.: Primary carcinoma of the nail, J. Am. M, Ass., 144: 19-21, Sept 2. 1950. 157 CHAPTER XI CONDITIONS INVOLVING THE THOPAX AND DOBSAL SPINE By Lloyd W. Taylor, Lt, Colonel, MC Chief, Orthopedic Section Fitzsimmons Army Hospital I, Scoliosis A. General aspects B. Treatment 1. General 2. Medical 3. Surgical C. Case reports II, Other conditions of dorsal vertebrae A, Ankylosing spondylitis B, Extra-lumbar disc herniae C, Scheuermann's disease D, Parasitic infections E, Miscellaneous conditions III, Conditions of thoracic vertebrae Of the thirty-five articles in this chapter, articles on scoliosis com- prise the majority. Other conditions of the dorsal and thoracic vertebrae account for the remainder. Scoliosis The first group of references deals with general aspects which have a bearing on scoliosis. The mechanism of rotation is explained by AHKTN (l). He bases his conclusions on a study of fifty-four anteroposterior roentgeno- grams of the spine taken in eight living subjects. The mechanism of rotation and lateral deviation of the spine is discussed at length and illustrated with diagrams and classical x-rays. In adults, convex side rotation anpears when the spine is in lateral deviation, whether in flexion, extension, or neutral position; this tendency is strongest in flexion and weakest in hyperextension. In only one patient is there noted even slight concave side rotation, and this is produced when the patient is in a position of passive lateral deviation in extreme hyperextension. Concave side rotation, therefore, plays no part in clinical structural scoliosis. The intrinsic mechanism for rotation, in com- bination with lateral deviation, in the normal spine depends upon soft tissue tension rather than upon arrangement of the articular facets. The behavior in scoliosis can be summarized by stating that the structure under the greatest tension will describe the straighter line. (Ed: This is an excellent article and should be read by all people interested in spinal scoliosis.) BROCHHR (2) 158 discusses this mechanism from clinical and x-ray observations and classifies scoliosis as being compensated or decompensated. SKRTGIN (3) and VAN DIMARK (h) review the classification and treatment of scoliosis in children. PONS WI and FRIIDMAN (5) give a well-documented and well—illustrated analysis of the prognosis in idiopathic scoliosis based on a study of cases not treated surgically. Of these, 335 are observed through maturity. The cases are divided into five main patterns as follows: main lumbar, main thoraco-lumbar, combined thoracic and lumbar, main thoracic, and main cervical—thoracic. Tran- sition forms are also seen between these primary classifications, but in most instances they can arbitrarily be classified into one group or another. As a whole, the main thoracic curve increases to greater deformities than the other patterns studied. The prognoses in the main lumbar, thoraco-lumbar, and cervi- cal thoracic curves are usually favorable, while the prognosis in the combined thoraco-lumbar curve is usually good only if it develops after ten years of age and poor if it starts earlier than this age. In general, the prognosis is de- pendent in a great measure upon the age of the patient when the curvature de- velops. The most deforming curves originate at an early age, and, conversely, the curves detected when the maturity of the patient is well advanced increase only slightly or not at all. Of all the groups, the main thoracic curve usually appears at the earliest age. The idiopathic curves almost always increase dur- ing the growth of the skeleton, and they cease to progress about one year before the completion of the ossification excursion of the iliac apophyses, (Ed: This is an outstanding article on idiopathic scoliosis, and the attempts of these authors to analyze their findings and lend some degree of reliable prognosis is most noteworthy.) Various methods of treatment for scoliosis are suggested, Surgical pro cedures are proposed by RELGRANO (6), FREDENHAGEN (?), LANCS (R), and FELIX (9). DS SEZE and LEVERNIEUX (10) describe the use of vertebral traction in the correction of scoliosis, and ITrSEVICH (11) cites the use of thoracoplasty. KWALWASSER (12) reports a case of a patient with a severe right thoraco- left lumbar scoliosis, treated with electric shock therapy. He states that nine electric shock therapy treatments were administered to this patient pre- ceded by 3 l/2 cc. of intocostrin and followed by 1 cc. of prostigmine 1000- 2000, The psychiatric diagnosis was involutional psychosis melancholia, from which the patient had been suffering for eight months, and nothing was con- sidered sufficient or helpful except electric shock therapy. Despite the severe deformities of her spine, this patient is reported to have had no diffi- culty following her treatments and no fractures as a result of the shock therapy. Several illustrative case reports are given, ARKIN et al (13) report a patient having received large doses of x-ray therapy as a child in the treat- ments of multiple benign melanomata of the back and embryonal adenocarcinoma. Grade III, The scoliosis, in this case, conforms to the deformity wvlch would be expected if the growth of the epiphyses on the left side of the lumbar bodies had been retarded. The authors state that the irradiation, which the patient received at the age of nineteen months, was directed to the left side. They point out that this is the only case of induced radiation scoliosis reported in the literature, (Ed: This report is most interesting.) 159 In an experimental study on radiation scoliosis, ARXIN and SIMON (1*0 report the results of their attempts to produce scoliosis in the spines of rabbits by the use of roentgen rays. A review of the past works in the pro- auction of this deformity by use of radium is given# The bone wedging pro- ducing this scoliosis is not the result of pressure from structural scarring in the concavity of the curve due to radiation,because the intervertebral discs are wider, indicating less pressure on the irradiated side. A single dose of 1000 R. is required to Induce definite wedging in the spines of young rabbits, and this may be of clinical significance in the control of scoliosis# R035)J4ReR (15) reports a case of olisthetlc scoliosis caused by aplasia of a sacral articulation. A case of kyphoscoliosis complicated by paraplegia is described by PEPTJSI (16). Other Conditions of Dorsal Vertebrae Ankylosing spondylitis is selected for discussion by KNUTSSON (17), FORESTIER and CERTONCINY (18), LIESCH (19), GRUCA (20), and ZAROKRZYCKI (21). Most of the papers are devoted to case reports, but early x-ray diagnosis is stressed# STUART and ROSE (22) describe the management of severe spinal deformity in a thirty-four-year-old patient by osteotomy between the first and second lumbar vertebrae, after la Chapelle with bone graft over the osteotomy site three months later. They report an uncomplicated post-operative course with no shock, ileus, or root pain, patient being allowed up six months after the firs operation. Illustrations Include patient before and after surgery as well as skeleton marked at osteotomy site* Extra-lumbar disc hernias are described by DELACROIX (23) and LOVE and KIEFER (2*0. The latter outline the experiences in the Mayo Clinic in the treatment of seventeen cases of root pain and paraplegia due to protrusion of the thoracic intervertebral discs. This incident is reported twelve times in a period of ten years, from 1938 through giving an incidence of approxi- mately two or three cases of protruded disc in the thoracic region per one thousand cases of ruptured discs in the entire spinal column. The rupture is seen one time at the fourth interspace, three times at the fifth, three times at the sixth, two times at the ninth, three times at the tenth, and five times at the eleventh. The symptoms and signs of these cases vary widely depending upon the size of the protrusion, its location in regard to the spinal column, and its situation in regard to the spinal cord, Ro clear-cut, true, recogniz- able, clinical entity exists. Diagnosis of a space-taking lesion, in the majority of cases, is established on myelographic examination of the spinal canal. Treatment of these cases consists of laminectomy, with removal of the protruded fibral cartilage, in fifteen instances and of decompression of the cord, without removal of the protruded disc, in two cases. The results of surgical treatment are outstanding in only those cases with root pain or cord compression, or both, without gross neurological defects. The patients with marked compression of the cord prior to operation usually have residual signs and symptoms indicative of irreversible damage to the cord itself. In order to obtain better results, earlier recognition is required, and treatment should be instituted before irreversible changes to the cord occur, (Ed: This excellei 160 article, by these experienced authors, should he read by everyone interested in rupture of the intervertebral disc of the spine.) Scheuermann1s disease, or necrosis of the epiphyses of the vertebrae, in adolescents is reviewed hy PRAHULOTIC (25) and hy LAHGEROH and LIEFOOGHE (26). Rstrasitlc infections of the vertebrae are cited by two authors. A case of echinococcosis of the vertebrae is reported by CAVIHA (27) who reviews the differential diagnosis of disc hernia. BEFTASSI (28) discusses what he calls melitococcic spondylitis which appears to be echinococcus infection. Miscellaneous conditions of dorsal vertebrae Include a case of "clay shoveller's” fracture by muscular avulsion of the spinous process of the first dorsal vertebra, reported by VBRDSJO and SANZ (29)• Other conditions which involve the vertebrae are discussed in case reports by SCHAFFER (30) on vertebra plana and by CHIARI (31) on multiple exostoses of the spinal column in acromegaly. Conditions of the Thoracic Vertebrae Early calcification of chondro-costal cartilage in spondylarthritis ankylopoietica is reported by ROTES QUEROL (32). JAROS (33) reports an isolated fracture of the first rib during gymnastics, and MULLER (3*0 reports a case of perforation of the heart by a fractured rib. A case with the slipping rib syndrome is reported by TELFORD (35)* and the anatomy, etiology, symptomatology, diagnosis, and treatment are discussed. Anatomically, the eighth, ninth, and tenth ribs do not communicate with the sternum, but each rib is attached to the one above by dense, fibrous mesh which surrounds an embryochondral synovial membrane and its joints. Etiologlcally, this syndrome arises from direct or indirect trauma to the chest wall, whereby the protective capsule is torn, allowing the anterior end of a false rib to curl under the cartilage above and impinge on the Intercostal nerve or its accompanying sympathetic. Symptomatically, pain, freouently dull and recurrent over a period of years, is a cardinal sign of a slipped rib. However, this pain may be sharp and lancinating, and, if occurring on the left side, it may simulate a heart attack. The pain is exacerbated by deep inspiration, ercira- tion, or sneezing, and, in some instances, by movement of the body or upper extremities. Ordinarily, the pain follows along the distribution of the inter- costal nerve around the thorax to the back. However, by way of the sympathetic nerves and their connections to the epigastric, hypergastric, and cardiac plexuses, pain radiating from the thorax to the upper abdomen, the neck, breast, and inner aspect of the arms is not uncommon. Diagnostically, this syndrome can be ascertained if the abdominal muscles are relaxed and the hand of the examiner clutches the costal margin and manipulates it backwards and forwards while pressure is applied over the sternum with the other hand. The patient's symptoms are reproduced by this maneuver, and the hand of the examiner frequently detects this click or determines the hyperraobility of the cartilage Involved, The treatment of this condition is either medical or surgical, depending on the frecuency and severity of the attacks. This article serves as a reminder of this rare condition which should be considered in patients having pain in the anterior chest wall, the abdomen, and even the neck, breast and inner aspect of the arms. 161 BIBLIOGRAPHY 1, Arkin, A. M.: The mechanism of rotation in combination with lateral deviation in the normal spine, J. Bone Surg,, 32 A: 180-8, Jan 1950 2. Brocher, I. B. W,: Compensation et decompensation vertehrale, Praxis, 39r 711-6. Aug 17, 1950 3* Skrygin, V. P.: Therapy and classification of scoliosis, Tr. Tsentr. nauchonoissledov. inst. protez., 3! 47-70, 1949 4, Van Demark, R. B. j Lateral spinal curvature (scoliosis) in children, S. Dakota J. M., 3: 13-16, Jan 1950. 5* Ponseti, I. V, and Friedman, B.j Prognosis in idiopathic scoliosis, J, Bone Surg., 32 A! 381-95, Apr 1950 6. Belgrano, M.: la cura chirurgica della scoliosi, Arch, ortop., 63? 200-14, Apr-Jun 1950 7* Predenhagen, H.; Zur Behandlung der idiopathischen Skoliose, Zschr. Orthop., 79? 476-84, 1950 8. lance: Surgical treatment of essential scoliosis, Mem. Acad, chir.. Par., ?6: 417-9, Mar 22-29, 1950. 9* Felix, W,! Surgical therapy of scoliosis. Arch, klin. Chir. (langenheck1 s), 265? 470-94. 1950 10. Seze, S. de and Levernieux, J.? Precisions sur des tractions vertehrales, Sev, rhumat., 17: 303-4, June 1950 11. lusevich, I. S.: Thoracoplasty in scoliosis, Vest, khlr., 70: 36-41, Feh 1950 12. Kwalwasser, S.: A case of marked S-curve scolioses and marked lordosis treated hy electric shock therapy and curare, Psychiat. Q., 24; 1-16, Jan 1950 13* Arkin, A. M,, Pack, G-. T., Ransohoff, N. S., Simon, • Padiation- induced scoliosis; a case report, J. Bone Surg., 32 A; 401-4, Apr 1950 14. Arkin, A. M. and Simon, N.: Radiation scoliosis; an experimental study, J. Bone Surg., 32 A: 396-401, Apr 19$0 15. Roederer, T. R,: Un cas de scoliose olisthesique causee par I'aplasie d*une articulalre sacree. Rev. rhumat., 17: 313, June 1950 16. Perusi, A.: Un caso di cifoscoliosi complicate da paraplegia, Arch, ortop., 63: 144-9, Apr-Jun 1950 17. Knutsson, F,; Fusion of vertebrae following non-infectious disturbance in the zone of growth, Acta radiol.. Stock., 32: 404-6, Dec 31, 1949 162 18. Forestier, J. and Certonciny, A.! Le diagnostic precoce de la spondyl- arthrite ankylosante, Medecin fr., 10: 155-7, Jane 10, 1950 19. Liesch, E.: la spondilite anchllosante, Minerva med.. Tor., 25-7. July 7-1^» 1950 20. Gruca, A.; Spondylitis ankylopoetica, Leczenie ortopedyczne, Polskl tygod. lek., $: 359, Feb 27, 1950 21. Zabokrzycki, J.: Spondylitis ankylopoetica (radiologica)., Polskl tygod. lek.. 5: 359. Feb 27. 1950 22. Stuart, F. W. and Rose, 0. K.: Ankylosing spondylitis treated by oste- otomy of the spine, Brit. M. J., 1: 165, Jan 7, 1950 23* Delacroix, R.: Extra-lumbar disk hernias, Echo raed. nord., 21: Feb 1950 24. Dove, J. 0. and Kiefer, E. J.: Root pain and paraplegia due to protrusions of thoracic intervertebral disks, J. Reurosurg,, 7? 62-9, Jan 1950 25. Franulovic, P.: Scheuermann’s disease, Voj. san. pregl., 7: 51-3. Jan- Feb 1950 26. Langeron, L. and Liefooghe, J.; Eplphysite vertebrale douloureuse des adolescents; maladie de Scheuermann, J. sc. med. Lille, 672 537-*'Ll. Dec 25. 19^9 27. Cavina, C.: Considerazionl su dl on caso di echlnococcosl vertebrale; specie in rlferlmento alia D. D. dl ernia del disco, Arch, ortop., 63? 135-^3. Apr-Jun 1950. 28. Benassi, E.: Radiological aspect and physiotherapy of raelitococcic spondylitis, Sicilia med., ?: IhO, Mar 1950 29. Ferdejo, Y. and Sanz, J. M.; Enfermedad de los cavadores y peones; a proposlto de un caso de fractura por traccion muscular de la apofisls espinosa de la primera vertebra dorsal, Med., Madr., 7 pt.2; 159, Sen 1. 19^9 30. Schaffer, ¥.: Beltrag zum Kranheitsbild der Vertebra plana, Oesterr. Zschr. Kinderh., ki 293-300, 1950 31. Chiari, H.: Uber multiple Exostosenbildung an der Wirbelsaule bei Akronmegalie, Wien. klin. Wschr., 62; Ij-73-6, July ?, 1950 32. Rotes Querol, J.: Les calcifications precoces des cartilages chondro- costeaux dans la spondylarthrlte ankylosante. Rev. rhumat., 17: 31^-5, June 1950 33* Jaros, K,; Isolovana zlomenina I. zebra pri telocvi.iu, Rozhl. chir., 29 : 213-6, 1950 Muller, K. L.: Perforation of the heart by a fractured rib, Wien. med. Wschr., 100; /*22-u, June 21, 1950 35* Telford, K. M.J The slipping rih syndrome, Canad. M, Ass. J., 62? May 1950 CHAPTER HI L0¥ BACK By Robert S. Brua, Colonel, USA?, (MC) and Herbert ?. Block, Lt. Colonel, USA?, (MC) USAF Hospital lackland A?B, Texas Assisted By S. P. Moorehead, MaJ., USAF, (MC) T. W, Meriwether, Capt., TTSAP, (MC) E. R. Maier, Capt., TJSAP, (MC) J. O. States, Capt., TJSAP, (MC) R. M. Tinian, MaJ., TJSAP, (MC) R. J. Miller, Capt., TJSAP, (MC) R. P. Holt, Capt*, TJSAP, (MC) H. A. Penner, Capt., TJSAP, (MC) Jose Gonzaga de Carvalho, Capt., Brazilian AP, (MC) I. Low back conditions A. Anatomical B* General C. Conservative treatment D. Psychosomatic E. Surgical treatment F. Spondylolisthesis G. Miscellaneous II. Ruptured disks and allied conditions A. Anatomical B. Roentgenology C. General discussion and etiology D. Diagnosis E. Treatment P. Results of treatment III. Miscellaneous There are 112 articles on conditions of the low back abstracted in this chapter. Articles dealing with the intervertebral disc syndrome are grouped together. Low Back Conditions There are seven articles abstracted on anatomical studies. TANZ (l) makes a report on x-ray studies of 57 subjects made to determine the normal range of motion at the *fth and 5th interspaces. The range of motion in both decreased with age; the 5th Interspace loses its motion largely in youth; the interspace loss is more uniform and gradual throughout life. About 25 per cent of the subjects over 4-0 (the majority of the group) showed no 165 evidence of lumbosacral motion by x-ray* At first a compensatory Increase in motion of the interspace above was evident, but with age this motion also decreased* Alignment of the posterior lumbosacral articulations Is the subject of an article by GASEDTG and TTICHOLSOIT (2)* A normal anteroposterior view of the lumbar spine shows that the articular facets of the lumbar vertebrae lie in a sagittal plane, excepting those of L5-S1 where the Joint spaces are normally not visible. If they are visible, either uni-laterally or bi-lat- erally, they are anomalous. This anomaly leaves this articulation subject to unusual stress and strain, and is called the ”Puttl Deformity,” It can cause chronic back pain and sciatica. In an x-ray study of the vertebral neural arch ossification in *K) chil- dren, ROWE and ROCHE (3) visualized a high incidence (60 per cent) of the neurocentral synchondrosis on routine oblique views* This normal finding disappears between the third and sixth years* VLCSK W, in a short article, describes the venous plexus around the lumbar vertebrae as demonstrated by x-rays and contrast media. STURZMEGGER (5) states that 17-20 per cent of all lumbosacral spine x-rays show presence of spina bifida* The anomaly is rarely symptomatic in Itself. The author quotes one case with chronic localized pain following a heavy direct blow, cured by removing the fractured fragments of the spina bifida arch* SICARD (6) describes spina bifida occulta as a failure of closure of the neural arches from a disturbance of early embryonic development* This is said to occur once in five cases, or 20 per cent of all spines* In chil- dren with enuresis, 62 per cent showed spina bifida occulta by x-ray* GIORGIRI (?) discusses deep reflexes of the leg as aids in the diagno- sis of neurological conditions* In addition to the more familiar tests, he lists a number of other reflexes which may be tested, making about l*f in all. On chronic backache in general. KLEIEBERG (8) makes a plea for better physical examination and proper diagnosis in compensation low back pain. Many cases are diagnosed as herniated nucleus pulposus and spondylolisthesis without findings to back them up. These are capitalized upon by claimants attorney* The etiology and physical findings of the most frequent causes of low back pain are reviewed. PHAIM (9) reviews the problem of low back pain from the viewpoint of the compensation factors involved, Ee asks for an awareness of the psycho- somatic factors brought into play by accident cases with possible compensa- tion* BLACKSTOITE (10) describes x-ray views necessary for low back studies# In an article on degenerative lesions of the lumbar spine, BRIMFIEID (11) discusses spondylosis, spondylarthrosis, and degeneration of the inter- vertebral disk. He considers terms which imply an inflammatory process to be misnomers. Spondylosis is a degenerative lesion Involving the Vertebral 166 todies; spondylarthrosis, on the other hand, is a degenerative lesion of the articular facets» Probable etiological factors and principles of management of these senescent conditions are outlined. RAVAULT et al (12) review their 373 cases of sciatic pain and list the usual causes. They conclude that malformations of lumbosacral column may be the cause of sciatica in 23 per cent of the cases. A description is given by HERSCHEL et al (13) of 12 cases of low back pain, together with a discussion of each case. In each a cause was proved, or an acceptable probable diagnosis was made. A contribution to the diagnosis of athletic injuries is made by K5T0T- SCHNIG (1*0, He stresses particularly the difference between the origin of the injury, usually considered by the patient as quite unimportant, and the pattern of symptoms. Younger prople often complain about sciatic symptoms which are refractive to treatment. The spine should be x-rayed in all such cases. BAUMAN and RONNEN (15) give a general review of some aspects of this crux medicorum: the low back pain. They describe cases which they treated at the military hospital at Batavia^ In discussing conservative treatment. COSTS et al (16) review the var- ious medical treatments of lumbo-sciatica; rest in bod and traction seem to be the most valuable, followed by the wearing of a good corset. They con- sider that complete relief can thus be obtained in a great number of cases. About one-fifth of severe sciaticas do not respond to the usual conserva- tive procedures and must undergo surgical Intervention, KLEINBERG (1?) describes sciatic scoliosis as a symptom complex aris- ing from a disorder of the low back. The important problem is to identify and localize the lesion. The majority of patients with sciatic scoliosis can be relieved by conservative treatment. Stretching of the low back and sciatic nerve under anesthesia followed by application of a unilateral hip spica cast is recommended, with subsequent use of a brace, exercises, and physiotherapy. SCHAUBEL (18) considers spinal manipulation a valuable means of treat- ment of acute or chronic backache where no organic cause can be found or where the cause is a herniated disc. Cases most amenable to manipulation therapy are those in which the pathology is presumed to be Interference with interarticular joint movements by subluxation, the presence of adhesions, or of muscle spasm. The types of manipulations used are described. SCOUGALL (19) and YOUNG (20) outline the accepted methods of conserv- ative treatment. The latter warns that back pain in adolescence may be psy- chogenic. STRONG (21) makes an attempt to classify cases of low ‘back pain which fall into the category of fihrositis. Evidence is presented to show that this syndrome can he explained by a mechanism involving the sympathetic nerv- ous system with its vasomotor effect, the localized muscle spasm with subse- quent production of local and referred pain in a segmental distribution. 167 Whether the etiology he of a rheumatic, traumatic, or an infectious nature, a myalgic lesion develops from which the secondary phenomena originate* A reflex action is set up and all forms of therapy, whether they he medical, mechanical, manipulative, or chemical, tend to break up the reflex mechanism* Stress is placed on a more complete examination of the hack* Guarded mani- pulations of the hack and judicious use of procaine is recommended* In a review of recent articles on the -psychosomatic aspects of low hack pain, PAUL (22) reports an incidence of a psychogenic basis averaging 10 per cent in the low hack cases studied* This survey shows the need for more case studies of patients with low hack disorders* The diagnosis of psychogenic heck disorder is frequently missed* PADOVABI and SACHET (23) present the results of study of 12 cases of backache in which no clinical or radiological evidence of an organic lesion could he found* These backaches involved principally the cervical and upper dorsal spine* In each case psychiatric investigation revealed a sexual dis- turbance* In all cases disappearance of the symptoms followed psychotherapy* Traumatic neurosis, psychosis, and malingering are discussed as they relate to industrial head and hack injuries by BARO The importance of a complete initial examination, including a neurological examination and x- rays is emphasized* The author, however, does not recommend lumbar puncture or myelography in hack injuries unless there is strong evidence for a herni- ated disc* When no significant pathology is found, the patient should he referred to a psychiatrist as soon as possible* TUFO (25) expresses the opinion that increased muscle spasm following injury is often due to psychologic causes or to a conversion hysteria* He further states that this increased muscle tension is frequently an etiolog- ical factor in rheumatoid arthritis* PADOVANI et al (26) discuss “back pains which are an aspect of the de- pressive state which has been termed neurasthenia* The relation to sexual disturbances is very clear in this depressive sequence. It is in the form of a chronic and anxiety-producing lack of harmony between feelings and sex- uality. A very large proportion of the patients (mainly female) had had a surgical operation in the lower abdomen or a gynceologlcal treatment involv- ing intravaginal manipulations. There is, he states, often a very clear re- lationship between these operations, sexual disturbances, and vertebral pains. In discussing surgical treatment, RICARD and FRARCILLON (27) report seven cases whore Wilson*s type fusion using a metal plate affixed to the spinous processes of the involved vertebrae was used; six in the lumbar spine and one in the lower dorsal spine. The authors have a guarded acceptance of the procedure, but report good results* A description of 12 cases in which Bosworth H-graft type of fusion was used is given by PICAUD and POUCEL (28). These cases included Pott*s dis- ease, vertebral fractures, spondylolisthesis, etc. The authors state the results were uniformly good* They mention that the patients tended to go into shock when the iliac graft was being taken, and recommend use of at least one liter of blood plus other fluids during surgery* 168 CHIGOT (29) reports on the use of a pneumatic halloon or hag under the iliac crests to control flexion and extension of the lumhar spine during spinal fusion, particularly of the Bosworth type, where it is desirable to produce more flexion of the spine when the graft is put in place* The use of an inflated hag during operation permits deflating to produce extension* This type of hag permits better abdominal respiration* MGrH et al (30) present a technique for spine fusion using a large iliac hone block wedged between the spinous processes of I>5 and the sacrum in the Bosworth manner* In addition the facets are denuded of cartilage and fixed with screws* Postoperatively the patient is kept in bed for three weeks* A cast is used only if the graft is unstable* Healing is considered complete in six months. 60 patients have been treated this way; 21 without screw fixation of the facets, and 39 with screw fixation* The authors do not cite specific results, but they feel that theirs were better with screw fixation* According to PERROT (31) the fusion operation should ho performed as a supplement to removal of a protruded intervertebral disk* He feels the operation of Bosworth using iliac hone has a double advantage of furnishing a rich source of spongy hone for Incorporation in the graft, and of furnish- ing a secure fixation of the graft site. Spondylolisthesis is discussed comprehensively by CAMPAHAHIO (32), who states that the defects of ossification in spondylolisthesis are primarily congenital, but the forward displacement of the body is due to superimposed trauma* He warns not to confuse spondylolisthesis with anomalies such as "brachispondylia" (hatchet shape vertebra) or "platyspondylia" (broad verte- bra). It is necessary to differentiate actual fractures where the whole vertebra is displaced* FERHAHDEZ EOZAS (33) points out that the medico-legal aspect of spondy- lolisthesis in industrial accidents is very important* The difficult ele- ment lies, according to the author, in the estimation of the actual value of the symptoms, compared with the history and evidence of the Injury. In all cases of accident, the physician should obtain the history so minutely that he can analyze the mechanics of the injury and roentgenograms should be made of every injured back. The author concludes that spondylolisthesis is pri- marily congenital, but usually the actual displacement is due to acute trau- ma, or indirect trauma of constant labor. In Argentina, as in other parts of the civilized world, an employer is liable for compensation when an em- ployee appears with spondylolisthesis aggravated or accelerated by an acci- dental injury sustained in the course of employment. MARIQUB (3*0 considers spondylolisthesis which accompanies fracture of articular processes* The x-ray pictures and clinical symptoms are very much like ordinary spondylolisthesis* The lumbar pains of these patients are out of proportion to the vertebral displacement and those coming to op- eration may have only a very slight displacement* CrIEAUD et al (35) report a case of spondylolysis of the neural arch of L5 with sciatica which has normal x-rays in anteroposterior and lateral views. The lesion was only disclosed by stereo-oblique views of LS Joint. They recommend routine stero-oblique views* 169 (36) description of spondylolisthesis of the 5th lumbar ▼ertehra is given as a contribution to the etiology of lumbar pains in chil- dren* This condition is a rare finding in children probably because it rare- ly gives sufficient symptoms to warrant study. The occurrence of shifting of the vertebrae in children can be assumed only on the basis of a congeni- tal fissure of the interarticularis portion* A case of symptomatic spondylo- listhesis in an eight year old child is reported* BUSTOS (37) feels that the posterior fusion operations of Albee and others for spondylolisthesis, etc*, are not effective. He believes that the ideal method of fixation can be obtained by the Chaklin arthrodesis* Chak- lin (1931) constructs an anterior buttress by removal of the intervertebral disc and adjacent bony surfaces of the bodies of the fifth lumbar vertebra and of the first sacral vertebra, and introduces in this space a transplant bone wedge. Chaklin performed the operation by an anterior abdominal extra- peritoneal approach. The author suggests the Chaklin operation by an anter- ior transperitoneal approach as the ideal operative treatment for persistent low back pain or deformity from spondylolisthesis or scoliosis. PERHOY et al (38) report a case of sacrolisthesis; (retrospondylolis- thesis )(Slcard); hierollsthesis (Lippens). Positive findings in x-ray were: (a) sacrolumbar subluxation forward, (b) reduction in the lumbar curvature, (c) narrowing of L5-S1 interspace. Displacement of the sacrum, they state, may result from congenital anomalies, postural defects, infection, disk dis- turbances, and severe or repeated minor traumas. Sacrolisthesis in women may be due to obstetrical conditions. The authors suggest orthopedic mea- sures for treatment of the sacrolisthesis, and Albee fusion when the patient continues to have severe pain after nonoperative treatment. Under miscellaneous, lumbar fat herniation is the subject of a paper by DAL LAGO and VERA (39) • It has been shown that fat tumor in lumbosacral area may produce subjective symptoms identical with those of lumbago, and removal of these tumors relieves most of the symptoms, giving the best re- sult* DITTRICH (J*0) describes cases in which a diagnosis of lipoma in the region of the sacrum, or of herniation of fat through lumbar fascia was made, and claims cure of low back pain and sciatica by excision or by local nerve block or regional anesthesia, in high proportion of cases. AUDIER et al (hi) report a case which resembled a herniated disc clin- ically, but which had a slow onset and had bilateral manifestations. At op- eration it proved to be a tumor within the cord at level of L3-Lh which part- ly eroded the bodies of these vertebrae. Histologically it was called a chordoma. Treatment by excision and postoperatively by radiation therapy was discussed. Ruptured Disks and Allied Conditions Anatomical and clinical studies on lumbar disc degeneration 1)7 TRI- BERG and EIRSCH (h2) are based on observation of 100 cadavers in which x- rays of the spine were taken after it was dissected out. 15 cases were un- stable and 1? cases had degeneration of the disc. Conclusions from the pathoanatomical studies were that disc degeneration gives clinical findings 170 when the annulus ruptures, that raptures usually take place in the lower lumbar interspaces, that they occur posteriorly, and that the presence of a reduced Interspace, sclerosis or osteophytes of the adjacent hone indicate a severely degenerated disc* Degeneration accompanies actual rupture of the disc* Clinical studies on 3°72 cases who had degenerated discs, and who represented 38 per cent of the total number of patients treated for low hack pain, showed that 57 per cent occurred in males, that manual laborers had no more than the general population, that 75 per cent of the degenerated discs occurred at 1A and L5. They also concluded that flexion-extension lateral x-rays of the lumbosacral spine were useful diagnostic adjuncts. HABLEY studied the effect of intervertebral foramen encroachment on the nerve roots using cadaver spines. The normal nerve roots or ganglion occupied only one-sixth to one-fourth of the opening with a surrounding re- serve cushion space containing blood vessels, lymphatic fat and areolar tis- sue. They list the multiple factors that can produce foramen encroachment following disc degeneration. They urge careful exploration of the entire foramen in any operation to relieve nerve root pressure* KUHLEHDAHL (UU) and 70S SCHULTE and BORQ-ER (U$) independently present detailed and well written reports of anatomical and functional studies of lumbar disk hernia* On autopsy specimens LETOBLOM and HULTQVIST (4-6) found fibroblastic pro- liferation and vascularization of the nucleus pulposus in 25 per cent of the discs studied. This was interpreted to he a result of trauma and a form of healing, hut subsequent to absorption of the disc material. Clinically ab- sorption of prolapsed portion of herniated disc does take place and symptoms may disappear. The reaction also leads to fibrosis in region of discs, longitudinal ligaments, dura, roots, ganglion and nerves. SSZS and MERLE conclude that twice as many patients with L5 sci- atica stand with sciatic scoliosis as patients with SI sciatica* The dif- ference corresponds to the difference in physiology between the disk, which is very mobile laterally, and the L5-S1 disk, where the lateral mobil- ity is usually very limited. The forward lateral flexion is very often a- dopted by the patient afflicted with L5 sciatica, since usually it brings about a lateral opening of the IA-L5 disk, which causes an effective decom- pression of the hernia. In many cases of SI sciatica, due to the absence of lateral mobility, the patient cannot effect a lateral gaping and decom- pression of the hernia* WILBERO {'48) presents results of dissection of lumbar and sacral spines and confirms the existence of a nerve which arises distal to the ganglion, passes back through the intervertebral foramen into the spinal canal and there divides up, Nerve fibers were found in the ligamentous coverings of the disc. It was also shown that stimulation of surface of the disc at surg- ery caused pain but stimulation of the surface of the vertebrae or the lig- ament urn flavum did not* Careful roentgenological technique, states K07ACS can render un- necessary 80 per cent of the myelograms done in the examination of the discs, LI to SI, The four most helpful points are (a) narrowing and wedging of the disc space, (b) osteophyte formation in the ligaments, (c) shift of the ver- 171 tebral body with stress, and (d) sciatic hook formation. There are 253 myelograms reported by FORD and KEY (50), They were done for low back pain and 206 of these cases were operated upon. Myelogra- phic diagnosis was accurate in 72*3 per cent of 206 cases. There were minor discrepancies in 8,3 per cent and major discrepancies in per cent. The optimum quantity of Pantopaque for demonstration of pathology and avoidance of reaction was 3*3 cc, (one ampule). Of this series 2? patients with nega- tive myelograms had positive operative findings. For contrast radiography of the peridural space, ALBRECHT and DRESSLER (51) recommend the method of injection of the contrast material Into the peridural space of the spinal canal in order to gain information about the vertebral bodies and intervertebral discs. Peridurography is tolerated bet- ter than myelography. Positive contrast medium seems preferable. The best results were obtained using a mixture of 20 cc, 35 Per cent Perabrodil and 15 cc, 3*3 per cent Pantokaln, The lumbosacral articulation Is only very seldom demonstrable, nevertheless this method seems useful. KRAMER (52) calls his method canalography, a roentgenologic examina- tion after extra thecal injection of an aqueous solution of a radiopaque or- ganic iodine compound into the epidural space hy the sacral route. Fo detri- mental effects were noted in patients thus examined. Some of the canalograms produced in the text show that it is possible to visualize irregularities in the shape of the vertebral canal. Little use has so far been made of the method for clinical examination, so the diagnostic reliability still has to be proved. The advantages of canalography, especially in comparison with myelography are considered. Since the radiopaque solution is totally ab- sorbed by the venous plexus and Is rapidly excreted by the kidneys, any form of myelography can still bo done afterwards. The extrathecal injection of opaque media offers great promise as a diagnostic method in cases where a- nomalies of the lumbosacral vertebral column are accompanied by neurological disorders. SXZX et al (53) mention the usual signs of radiological localization of herniated disc without use of Intraspinal contrast media. To these signs they add two. One is demonstrated by static anteroposterior and lateral x- rays of LS spine. Here they describe a relative widening of the disc space on the side of the lesion at the level of the lesion, shown as a relative widening of the space posteriorly in the lateral view, and on the side of the herniation on the anteroposterior view. The second is seen in flexion- extension and lateral bending views in upright position (all views described are in upright position). In this test, lateral bonding away from the side of the herniation shows uniform widening of the disc spaces on the side of the lesion, bending toward the lesion, the affected space stays open, the others narrow down. LONGrMORE (5*0» an x-ray technician, writes a short article pointing out that x-rays diverge from the tube to patient and that lateral films of the spine with the spine straight do not show the interspaces in their true aspect. He advocates curving the patient slightly to correspond with the arc of the diverging x-rays, to give a true projection of the Intervertebral spaces, either using a string attached to the tube to line up the spinous processes equally distant from the tube or using a curved cardboard cutout 172 to line up the spinous processes in a similar manner* Three cases are reported by ERNEST and HEILBURN (55) in which there were bizarre neurological findings suggestive of spinal cord disease assoc- iated with nerve root pressure* In all cases myelography was performed and in each the pattern of the defect showed a vascular component as the cause* The defects revealed themselves as pulsating, tortuous shadows of decreased density* All were confirmed by laminectomy* HAUSSLER (56) writes that in most cases of lumbar disc prolapses with neurological findings requiring surgery, the level can be determined with sufficient accuracy clinically* If the prolapse is above L4 or 15 level air myelography is of help* A peridurography may help if the prolapse is large enough and the position is low enough* No x-ray contrast process, e- ven myelography, can supply in every case definite positive or negative re- sults* BELZ (57)* in an article which appears somewhat contradictory, suggests that the use of lodopin myelography should be abandoned because it is not wholly innocuous* Because there does not exist a really safe contrast med- ium, air myelography is preferred. Air myelography gives satisfactory vis- ualization of tumors, but is loss satisfactory for arachnitis* Therefore, the myelography with air is first employed when a process in the spinal space is involved. If localization is not clear the injection of iodine preparations may be employed later* For a disk prolapse air myelography is the best method for localization of the affected disk* The technique of air myelography is described. Under general discussion and etiology, a large number of articles by authors of all nationalities were abstracted dealing with the subject of herniated discs in a comprehensive manner, including a discussion of the history, etiology, diagnosis, pathology and treatment* BRADFORD (56), KEY (59), NASH and PATTERSON (60), SIEHL (6l), APPEL (62), CHAPMAN (63), JAEGER and LEHMANN-FACIUS (64), GRONEMSYER et al, (65), KROLL and REISS (66), and GUSTILO and WALKER (6?) all wrote excellent articles of this nature. BODMAN et al (68) present a short article by a physician about his symptoms and his difficulties with his own herniated nucleus pulposus* SCHOLER (69) reviews the various etiological factors causing hernia- tion of the intervertebral disc. He divides the factors into two groups* (a) degenerative causes for herniated nucleus pulposus, and (b) traumatic causes for herniated nucleus pulposus. He mentions the usual causes in each group. ARNAUD (70) maintains that many lumbosacral Joint conditions are cap- able of provoking a sciatic attack* Sciatica in indicative of nerve root compression* Edema or slipped disc may cause nerve root compression* Man- ipulation and orthopedic treatment should be tried before cases are consid- ered resistant to medical treatment* In Hungary disc pathology occurs most commonly in the hardworking class at a ratio of 4:1, as compared to clerical help, according to ZOI/PAN (7l)» Conservative therapy is not the treatment of choice, since almost always a 173 complete cure occurs with surgery. Early surgical procedure eliminates the possibility of deformities of the lower back, which occur in the later stag- es, Complete cure in 89 per cent of the cases was found when treated early. Operation consisted of hemilaminectomy and curretting of the intervertebral disc without spinal fusion. Following operation, massage, exercise, and vi- tamin B therapy are given. WOOD (72) discusses etiological factors producing disk injuries, the usual signs and symptoms, and the operative treatment* He concludes that the patient should be given considerable conservative treatment prior to surgery, myelography should be employed in every case, it is necessary to localize the level and to rule out tumors, and the disk surgery should not include low back stabilizing operations* He feels good results should be obtained in at least 80 per cent of the cases. MANGINI (73) reviews the literature on sciatica and summarizes the cur- rent conception of the syndrome condition. E© concludes that sciatic pain is usually due to intervertebral disk herniation and recommends operative measures for relief of sciatica. A discusser states that orthopedic examin- ation of patients must follow the neurological examination and that nonoper- ative treatment will cure most cases of sciatica. In the consideration of diagnosis. KEY (7*0 states that low back pain in children usually yields evidence of disease. The existence of herniation of the intervertebral disc in children is not generally recognized. The Mayo Clinic reports an Incidence of 2.3 per cent over a three year period. The physical signs follow those of the adult with most recovering; 10 per- cent going to surgery. The pathology usually reveals an liitact annular lig- ament with a dome-llke swelling, elastic consistency and filled with a sem- ifluid grumous material. Conservative management consists of minimised ac- tivity (but continuing school), back support until asymptomatic, and postur- al exercises. In a long and detailed article, DECKER and BUFFAT (75) report a meti- culous study of chronic disorders of the vertebral column and call attention to the arthroses and to the intervertebral disk syndrome. Conclusions! Low back pain and sciatica may be due to conditions in the vertebral column (spon- dylitis, tumors in the vertebral column, traumatic causes, spondylolisthesis, etc.) or involving the pelvis or sacrum. Lumbago and sciatica are usually due to degenerative changes in the and 5th lumbar vertebrae. The degen- erative changes with hypertrophic arthritis occur with or without herniation of the disk. Low back pain is usually due to degenerative changes and sci- atica is due to herniation of the disk. However much wlumbago” is due to herniated disk, and a high incidence of sciatica is due to arthroses without protruded disk. In hie article, CRAMER (76) gives a list of even remote possible etio- logical factors and diseases which can cau.se sciatica. Since herniated nu- cleus pulposus is the commonest cause it must always he proved or excluded from the diagnosis. He discusses the disadvantages of the usual type of myelography. He feels that the low lumbar and upper sacral areas are not sufficiently visualized. He advocates sacral epidural injection of a con- trast medium ("per Ahrodll M", 35 per cent viscosity - Bayer) through the sacral cornu# 174 KEMP (7?) describee a symptom of prolapse of the intervertebral disc, which proved to be highly significant* It consists of a pain radiating from the area of a disk prolapse on carrying out a hyperextension movement of the vertebral column, especially when the hyperextension is done together with lateral bending toward the Hdisease” side* KIXrELBERG and PSTERSM (78) emphasize the importance of noting weak- ness and atrophy of M, extensor hallucls brevis in Lh disks* This muscle is involved almost twice as frequently as other extensor muscles of the foot* Also in their series, only 16 per cent of L5-S1 disks exhibit any muscle weakness or atrophy, 90 per cent of IA—L5 disks showed muscle weakness or at- rophy* GAMA. (79) reports two cases where neuralgic pain was wrongly ascribed to posterior hernia of intervertebral discs. He emphasizes that all proven herniations are not responsible for symptoms that sometimes coexist* The patients had typical pain, numbness and weakness but their symptoms were due to neuromas of the sciatica nerve* 130 consecutive cases of low back pain from the out-patient clinic of the University Clinics of Helsinki are reviewed by INBERG (80) to find the incidence of herniated lumbar disc. 23 or 18 per cent had proven herniations removed at surgery* Treatment is discussed in 1** abstracts* ADAMS (81) reviews the clas- sical symptoms of herniated nucleus pulposus and makes a plea for adequate conservative management prior to any surgical intervention* YOUNG (82) suggests that epidural injection of hypertonic sodium chlor- ide acts by reducing or abolishing edema of a nerve root by osmosis. Epi- dural injection of this solution is not likely to be of use if there are no symptoms or signs of nerve root involvement or if scoliosis, convex to the painful side, is present* BLANCHE (83) gives a resume of the anatomy, pathologic physiology, history, findings, diagnosis, and therapy of ruptured intervertebral discs. The opinion is expressed that manipulative therapy has very little value and is dangerous* Surgical therapy should consist of the combined procedure of removal of the herniated disc followed by fusion of the affected segment* MERCKELBACK (8*0 cannot accept an exclusive mechanical etiology in production of a herniated nucleus pulposus* He stresses the viewpoint of a frequent arthritic or rheumatic cause* He urges and adequate con- servative treatment before resort to surgery* He describes Bosworth'e fus- ion as a desirable adjunct to herniated nucleus pulposus operation. The author indicates that the widespread appreciation of the diagnosis and surg- ical treatment of herniated nucleus pulposus in Germany is much more recent than in the United States, A review of symptoms, diagnosis, and treatment of cases of ruptured intervertebral discs is presented by MUNSLOW and HINCEET (85)* The authors conclude that 90 per cent of the cases are amenable to conservative therapy, but it is not likely to aid those patients with actual motor weakness due to nerve root compressions. Surgery may bo expected to relieve those cases 175 that do not respond to conservative management. MAYR (86) reviews the impact of accident Insurance on treatment of cases in Austria. He mentions the relationship of acute injury from acci- dents as cause of recurrent and chronic conditions, especially in the low hade. Acute attacks of hack pain and/or sciatica can he brought on by a trivial hut unfamiliar twist or lurch of the body, and not necessarily by heavy work. Most cases can he cured or improved without surgical interven- tion. Because of the recent center of attention on surgical treatment of sciatica COST® (8?) points out that treatment was reasonable satisfactory before the etiology of the lesion was appreciated. He reviews the nonsurg- ical methods of treatment, including bed-rest with or without flexion posi- tion; traction, either on legs or pelvis; manipulation; x-ray therapy (not recommended); use of vitamin B-l; use of corset; and limitation of activity. About 20 per cent require surgery. He feels that many protruding herniated discs can spontaneously or by manipulation be reduced. Four cases are reported by ¥YCIS (88) in which contralateral sciatic pain appeared after removal of a ruptured intervertebral disc. The occur- rence was at the same interspace. Three of the cases were verified at oper- ation, the patients being relieved postoperatively. A fifth case is pre- sented in which ipsolateral symptoms were relieved by a contralateral remov- al of a partially herniated disc. SCHULLER (89) discusses cases with disc symptoms which come to surg- ery, but in which no disc was found, yet relief of symptoms is obtained. Some believe an inflammatory neuritis may be the cause, or a thickening of the ligamentum flavum causing pressure on the nerve root, or an exostosis causing pressure or a narrowing of the L5-S1 neural foramen. CREYSSEL (90) advocated arthrodesis of the intervertebral articulations following all surgical interventions for herniated discs. He concedes the value of bone grafts in traumatic conditions or in chronic backache of long duration without sciatica. HICARD (91) discusses the pros and cons of arthrodesis of the inter- vertebral articulations as a sequel to operative intervention for herniated intervertebral disc. With removal of a herniated nucleus pulposus and sub- sequent disc degeneration, proper distribution of forces at the particular interspace is disturbed, resulting in repeated trauma of the opposing verte- bral bodies. Lumbar sciatica occurs too frequently in these cases for one to be able to predict its ultimate absence or occurrence. Therefore, since arthrodesis is relatively simple, its use routinely is advocated in all herniated disc interventions. HAAS (92) having previously shown that fusion of the vertebral bodies could be accomplished when the intervertebral disc was removed through the transabdominal approach, attempts to see if the same fusion could be accom- plished through a posterior approach. The failure of complete union was due to the inability to remove sufficient disc tissue to expose bone on both ver- tebral bodies. This is more easily accomplished by the anterior or abdomin- al approach. 176 In an article on disc degeneration OLSEN (93) advocates spinal fusion after disc operation. His discusser agrees that there is a large group of patients which should have combined disc excision and fusion. He advocates consultation between orthopedist and neurosurgeon prior to operation to de- cide whether fusion should be done. He particularly advocates fusion where there is evidence of lumbosacral joint arthritis, or in patients that are to do heavy manual labor. EATON advocates surgical excision in proved cases which have not responded satisfactorily to conservative treatment. In those cases which present low-back manifestations of degenerative or traumatic pathology, in- ternal fixation by fusion has been effective in controlling the symptoms of the disease. Six authors discuss the results of treatment, HERBERT (95) optimisti- cally states that in disk sciaticas of unquestionable origin, when the hern- ia has been found at operation and removed, the results are excellent, Al- physical capacities may be somewhat limited, many who have been op- erated resume their former occupations. SHINNERS and HAMBY (96) present a follow-up study on 355 surgically treated and 200 nonoperated herniated nucleus pulposus patients, per cent of surgically treated patients stated they were cured; 29,5 per cent of the unoperated cases stated they were cured. Of compensation cases, 29 per cent of surgically treated were cured; 51 per cent of unoperated cases were not working. Overall picture: 91»5 per cent of surgically treated group wore working, 86 per cent of unoperated group were working. O'CONNELL (97) advises; '’Reserve disk surgery to those presenting signs after conservative therapy has been tried and results will be excel- lent," In his series of 500 operative cases, 92 per cent were completely asymptomatic or greatly improved. Mortality rate was per cent. KRAYENBUHL (98) reports on his clinical study of 998 cases operated on for herniated nucleus pulposus. Early and late postoperative results in h-59 of those operated are per cent cured, UO-Jl-5 per cent improved enough to return to work, and 10-15 per cent poor results. Operative mortality was 0,3 per cent. WAUGH et al (99) compare 70 cases treated surgically with 63 cases managed without operation, Generally the recurrent and more severe cases were operated on and better results were reported in these cases. At the end of 36 months, 69 per cent of operated cases could work full time, as compared to 53 per cent of conservatively managed group. HEPBURN (100) presents postoperative results following herniated nu- cleus pulposus excision in 170 patients with over one year follow-up, 62 per cent of the patients reported persistent numbness or paresthesia. The author is not in favor of immediate fusion as routine treatment. Miscellaneous LEHNER (101) reports four cases of acute metastatic staphylococcic ab- scesses in the spinal epidural space. All of them were successfully treated 177 without leaving any ill effects. Two proven cases of tuberculous spondylitis are reported hy GIULIANI (102). The disease developed into a calcification of the nucleus pulposos. They can he found in purely degenerative processes as well as in inflamma- tory diseases. These two cases are significant because the presence of tu- berculosis was proved. The case of a 22 year old male who received a spinal anesthesia for a herniorraphy three years before is reported by WILSON (103). During the ad- ministration of the anesthesia he felt a sudden sharp pain in both legs. Subsequently he had recurrent back pain brought on by strenuous activity. After two and one-half years the pain began to radiate down one leg. Oper- ation revealed a protruding disk impinging on the 5th lumbar nerve root. After excision of the disk the patient’s sciatic pain was absent. TOUMEY ©t al (104) report 48 cases of cauda equina tumor operated on over a 10 year period. 1056 cases of herniated nucleus pulposus were oper- ated during the period, Cauda equina tumor was 4,3 per cent of total. The symptomatology of cauda equina tumor and intervertebral disc is similar. Necessity for early removal of tumor, if success is to he attained, is stressed. Most important diagnostic factor is myelography. Seven cases of acute nontuberculous psoas abscess are reported by ZA- DEE (105)# This disease is rare and frequently misdiagnosed. Treatment is early drainage through a McBurney incision. The chief findings are flexion and external rotation position of the hip, a tenderness with or without a mass in the pelvic fossa, and leukocytosis. A case of echinococcus cyst of the psoas muscle proven at operation is reported by YBARZ (106). Spontaneous haematoma of the rectus abdominis muscle and a case is reported by MORRIN (10?)• The sacroiliac joint is discussed by two authors. ABEL (108) reports that of a series of 160 traumatic paraplegics, 98 showed abnormalities of the sacroiliac joints radiographically, varying from paraarticular rarefac- tion and narrowing of the joint space to complete bony obliteration. One biopsy of a joint demonstrating moderately severe involvement showed atro- phic bone with no evidence of a Joint space or articular cartilage. The lesions described are quite similar in appearance to the sacroiliac find- ings in Marie-Strumpells spondylitis. It is conjectured that similar etlo- logic factors may be operated* In two articles on chronic nontuberculous sacroiliac arthritis TNGEI*» RANS (109, 110) reviews the embryological development and the anatomical structures and relationships of the sacroiliac Joints. Diagnosis Is diffi- cult, Subjective pain is not pathoneumonlc. Localizing signs are sought for in movements on the relaxed patient which move the sacroiliac joints directly or indirectly. The hypothesis of a relaxed articulation seems rea- sonable. Cases are classed as those due to major trauma, those from minor trauma secondary to postural imbalance, malformation, spondylitis, congeni- tal lumbosacral malformations, those due to pregnancy and postpartum period, those due to sacroiliac osteochondritis (sacroiliac syndrome of adolescence of Rogers and Cleaves), those from infectious arthritis, and those from para- 178 sitic sacroiliac conditions. Treatment is first plaster immobilization, next sacroiliac arthrodesis, either intraarticular or extraarticiilar. MALAGUZZI (111) observes that patients suffering from lumbar arthrosis show with some frequency some white narrow stripes elevated on the skin in the lumbar region; more rarely one can find the stripes in subjects which do not complain of lumbar pain. Such changes show a greater incidence in wo- men than in men, particularly in the years of the menopause. The author points out that some constitutional and endocrine factors play a role in the pathogenesis of such changes. Reflexes of the vegetative nervous system caused by the pain in the deep tissues are important in the localization of such changes in the lumbar region. CASIRACrHI and FARRNGO (112) discuss lumbar hernia and describe the anatomy of Grynfelt's and Petit's triangles through which they occur. The etiology is believed to be congenital parietal dysplasia. 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Bone Surg., 32 A; 557-60, July 1950 Seze, S. de, and Merle, P.i Statistics and pathogenic interpretation of L5 and SI sciaticas, Presse med,, 57* 1081, Nov 26, 19^9 ij-8, Niberg, G,* Back pain in relation to the nerve supply of the inter- vertebral disc, Acta orthop. scand,, 19* 211-23, 19^9 F.ovacs, A,: Herniated disks and vertebral ligaments on native roent- genograms, Acta radiol,, Stockh,, 32* 287-303, Oct 31, 19^9 182 50. Ford, L. T., and Key, J, A,; An evaluation of myelography In the diagnosis of intervertebral disc lesions in the low hack, J. Bone Surg., 32 A: 257-66, Apr 1950 51. Albrecht, K., and Dressier, V.: Contrast radiography of the peridural space (peridurography); possible morbid modifications of vertebral bodies and intervertebral disks, Fortsch, Rontgenstrahl, ?2! 703-8, Apr 1950 52. 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Bradford, F, K.: Lumber intervertebral disc rupture, Dis, Nerv. Syst., 11: 3-19. Jan 1950 59* Key, J» A.: The diagnosis and treatment of intervertebral disc lesions in the low back, J, Oklahoma M, Ass., 53s 198-204, May 1950 60. Nash, C, C,, and Patterson, C. F.: The ruptured intervertebral disc, Dallas M. J., 35* 151-3, Nov 1949 61. Siehl, D,; Symptoms and diagnosis of herniated intervertebral disk, J. Am. Osteopath. Ass., 49, 509-12, June 10, 1950 62. Appel, J).; Diagnosis and treatment of herniated nucleus pulposus, Belg. tschr. geneesk., $'• 1143-55» Oec 15* 1949 63. Chapman, R, J.: Ruptured lower lumbar intervertebral disks; neurolog- ical aspects, J. Am. Osteopath. Ass., 49: 224-6, Dec 1949 64. Jaeger, F., and Lehmann-Facius, H,: Diagnosis and differential diag- nosis of intervertebral disk hernia, Med, Wschr,, 4: 417-22, June 1950 65. Gronemeyer, W,, TJthgenannt, H,, and Schumann, H.: Diagnosis and treat- 183 ment of intervertebral disk hernia, Nervenarzt, 21: 289-97, July 20, 1950 66. Kroll, F, W.f and Reiss, E,: Problem of sciatica and intervertebral disk hernia, Klin# Wschr., 28; May 15, 1950 6?. Gustilo, R. H., and Walker, A. E.; Herniated lumbar nucleus pulposus, its diagnosis and surgical management, Philippine J. Surg., 5* 99- 11D, May-June 1950 68. Bodman, P., McKlnlay, M,f and Sikes, K.: Prolapsed intervertebral disc, Lancet, Load., Is 177, Jan 28, 1950 69* Scholer, G.; Pathogenesis of the intervertebral disk, Wien, klin# Wschr*, 62; 298-301, Apr 28, 1950 70. Arnaud, M,; Surgical problem of lumbosciatica, Marseille chlr., 1; 510, Sept-Oct 19^9 71. Zoltan, I.; Disease of the intervertebral disks; chances for rehabil- itation, Magy. sebeszet, 3: 136-8, 1950 72. Wood, J. P.; The ruptured intervertebral disk syndrome from the orth- opedic surgeon's standpoint, J. Am. Osteopath. Ass., 227-30, Dec 19^9 73* Mangini, 6.; Sciatica and hernia of the intervertebral disk, Sicilia med., 7: Mar 1950 Key, J. A.; Intervertebral disc lesions in children and adolescents, J. Bone Surg., 32 A; 97-102, Jan 1950 75* Docker, P., and Buffat, J. D.; Chronic disorders of the vertebral column; arthroses and herniated disks, Helvet# chir. acta, 17: 187- 233, June 1950 76. Cramer, H.; Differential diagnosis of lumbosacral affections with special consideration of intervertebral disk hernia, Med. Klin#, 468-71, Apr 1950 77* Kemp, A.; A new symptom of intervertebral disk hernia, Red. tschr# geneesk#, 1750-5, June 2k9 1950 78. Kugelberg, E#, and Petersen, I.; Muscle weakness and wasting in fourth sciatica due to fourth lumbar or lumbosacral disc herniations, J# Neu- rosurg., 7s 270-7, May 1950 79* Oama, C.; Neuralgic pain wrongly ascribed to posterior hernia of in- tervertebral discs; report of two cases, J. Internat. Coll# Surgeons, 13: 578-82, May 1950 80. Inberg, K, R.; Frequency and differential diagnosis of lumbar disc herniation, Ann. chir. gyn. fenn., 38; 212-20, 19^9 184 81* Adams, J, C,: Prolapsed intervertebral disc with special reference to the use and limitations of conservative treatment, Med, Press, lond., 223: 5*0-7, June 7, 1950 82* Young, J. H,: Epidural injection of hypertonic sodium chloride solu- tion in the treatment of sciatica and other root pains in the lower limb, Med, J. Australia, 2: 530-2, Oct 1, 19*0 83. Blanche, D, W,: The ruptured intervertebral disc, Ann, Vest. M.&S,, 240-4, May 1950 84, Merckelhach, P. M. L,: Contribution to the treatment of herniated nu- cleus pulposus, Med, Wschr,, 3i 743, Oct 1949 85* Munslow, R. A,, and Hinchey, J, J,s Protruded intervertebral disk syndrome; conservatism in management, Texas J. M,, 46s Jan 1950 86. Mayr, S,: Intervertebral disk hernia and accident, Wien, med. Wschr., 100: 271-3, Apr 22, 1950 8?, Coste, P,: Nonoperative therapy of lumbar sciatica, Progr, med,, Par,, 78: 255-9, May 10, 1950 88, Wycis, H,: Contralateral recurrent herniated disks. Arch. Surg,, 60: 274-8, Peb 1950 89, Scheller, H.: Clinical aspects of herniated lumbar intervertebral disk and related pathological state. Dent, med, Wschr,, 75* 568-9, Apr 28, 1950 90, Creyssel, J.: Vertebral osteosynthesis by the Wilson technic, Mem, Acad, chlr,, Par,, 78: 160-6, Jan 11, 18, 19, 1950 91, Ricard, A,: Vertebral block for additional time in surgical treatment of lumbar sciatica, Mem, Acad, chlr,. Par,, 76: l**0-6, Jan 11, 18, 19, 1950 92, Haas, S, L,: Resection of the intervertebral disk through the poster- ior approach, Arch, Surg,, 59: 1261-4, Dec 1949 93« Olsen, K,: Disc degeneration; a distinct clinical entity, J. Nerv, Ment. Die., 112: 262-3, Sept 1950 94, Eaton, J, M,: An evaluation of the end results in 500 cases of hern- iated lumbar intervertebral disks, J, Am, Osteopath, Ass,, —: 7-10, Sept 1949 95* Herbert, J. J,: Indications for surgical treatment of sciatica, Caz. med. Prance, 57i 381-7, Apr 1950 96, Shinners, B, m,, and Hamby, W, B,; Protruded lumbar intervertebral discs; results following surgical and nonsurgical therapy, J, Neuro- surg,, 6: 450-7, Nov 1949 185 97, O'Connell, J. E, A.: Ihe indications for and results of the excision of lumbar intervertebral disc protrusions! a review of 500 cases, Ann, R, Coll, Surgeons England, Lond,, 6: *403-12, June 1950 98, Krayenbuhl, H,: Diagnosis and surgical therapy of herniated lumbar disk, Helvet, chir, acta, 17? 23*4-*45» June 1950 99, Waugh, 0, S,t Cameron, H, P,, Scarrow, E, G,, and Howarth, J. C,: Follow-up on lumbar disc leslonsr, Canad, M. Ass, J,, 61: 607-11* Dec w 100, Hepburn, H. H.! Herniated intervertebral disc; a survey of postoper- ative results, Canad. M, Ass, J,, 62: **37-9* May 1950 101, Lehner, A,! Epidural spinal abscess, Schwiez, med. Wschr,, 80: 917- 9, Aug 26, 1950 102, Giuliani, K.s Calcification of the nucleus pulposus, Zschr. Orthop,, 79: 279-81, 1950 103, Wilson, J. N,: Prolapsed intervertebral disk after lumbar puncture, Brit, M. J., 2: 133*4, Dec 10* 19*49 10**, Tourney, J, W,, Poppen, J. L,, and Hurley, M. T,: Cauda equina tumors as a cause of the low back syndrome, J, Bone Surg,, 32 A! 2*4-9-56, Apr 1950 105. Zadek, I.: Acute nontuberculous psoas abscess; a clinical entity, re- port of 7 cases, J, Bone Surg., 32 At *433-8, Apr 1950 106. Ybarz, P,: Echinococcosis of the psoas muscle, hydatid psotls. Arch, urug, med,, 36: 10*4-9* Jan 1950 107. Morrin, P, J,: Spontaneous haematoma of the rectus abdominis muscle, Irish J. M, Sc., —: 815-20, Nov 19*49 108. Abel, M, S,: Sacroiliac joint changes in traumatic paraplegics. Rad- iology, 55: 235-9* July 1950 109. Ingeirans, P.: Surgical forms of nontuberculous sacroiliac arthralgias and arthritis, Rhumatologle, —: 126-7* May-June 1950 110. Ingeirans, P.: Chronic nontuberculous sacroiliac arthritis, Bruxelles med., 30: 1811-20, Aug 27, 1950 111. Malaguzzl, V, C.: Presence of striped cutaneous dystrophies in pa- tients with lumbar arthrosis. Rev. rhumat,, 17: 279-89, June 1950 112. Casiraghi, J. C,, and Farengo, 0,: Hernia lumbar, Bol, Soc, argent, cir,, 10: 8*40-3, Nov 23-28, 19*49 186 CHAPTER XIII CONDITIONS INVOLVING THE HIP JOINT AND PELVIS By George H. Chambers, Major, USAP, (MC) 3750th Medical Group Sheppard Air Force Base, Texas Assisted By Jacques G. Robichon, MD Ingulf U. Medbo, MD University Hospital Iowa City, Iowa I• Hip pain A. General B. Diagnostic C. Non-operative treatment D. Palliative treatment E. Surgical treatment II. Hip trauma A. Dislocations B. Fractures III. Reconstructive surgery A. General B. Resection and osteotomy C. Arthrodesis D• Arthroplas ty S. Other methods IV. Pelvis A. Anatomical B. Coccygodynia C. Trauma There are 73 articles abstracted in this chapter on conditions involv- ing the hip joint and pelvis. Hip Pain Two articles deal with the consideration of hip pain in general. SAXL (l) considers the various insufficiencies of the hip in light of the various pathologic entities that may contribute. Stress is placed on the careful diagnosis of the various entities before treatment is to be started, SEZE and DURISU (2) remark on the role of vascular factors in the pathogenesis of coxarthrosis. There are at least four conditions in which a single and pre- 187 else cause, associated with important vascular lesions, can produce degener- ative changes of the hip joint, e.g. caisson disease, reductions of congen- ital luxation of the hip joint, traumatic luxation of caput femoris and cer- tain fractures of cervix femoris* Those data along with certain clinical and experimental findings are suggestive of the important part played by vascular factors in the occurrence of a great number of hip joint involve- ments* In the diagnosis of hip Joint pain, MAURER (3) writes briefly on the diagnostic criteria by x-ray of Perthes disease and illustrates this in a case* KLOPPER presents two cases of hip dislocation due to increasing interarticular pressure, one in a year and one-half old girl with inflamma- tory process and the other in a year old child with post traumatic exudation. ERANCON and PERLES (5*6) describe two tests for early diagnosis* With the patient on the back and hip and knee flexed (as Kernig's test), pressure on the knee causes pain* The second test is with the extremity extended and rolling from maximal internal to maximal external rotation. DAERIS (?) states that by radiography a minimal lesion with extensive pain Indicates nothing to be done to the Joint but denervation, injection, irradiation, and forage* With extensive lesions it indicates : (a) posterior dislocation - requires stabilization, (b) ankylosis with deformity - requires osteotomy, (c) incomplete ankylosis with aseptic necrosis - requires resection with ankylosis or arthroplasty* EORESTIER (8) tabulates movements of the hip' on which successive visit measurements are recorded for quick review. Under the heading of non-operative treatment ERANCON (9,10,11) gives a rather complete generalized discussion of arthritis of the hip from to 1938* This included anatomy, pathology, radiology, etiology and pathogene- sis in the first chapter* In the second chapter he discusses the early clin- ical manifestations as well as in the established and terminal cases* In chapter three he classifies the manifestations into various types in accor- dance with clinical findings, evolution, etiology and radiologic appearance. Chapter four deals with the criteria for diagnosis in light of the differ- ential diagnosis and prognosis* Medico-legal aspects are covered. In chap- ter five he resumes the treatment and discusses the prevention and curative means (medical, physiotherapy, spas, orthopedic and surgical). He concludes that multiple means are available for treatment requiring a judicious choice in each individual so that a well planned regimen will bring patient relief as well as attenuating the disease* ERANCIUON (12) describes the pathology of aseptic necrosis. He be- lieves that non-weight bearing is essential and puts the patients to bed with traction, and later ambulates them without weight bearing* Treatment is pro- longed several years if necessary* NAGEL (13) rev levs painful hips in adults from the etiology leading to the disability* Infection in childhood, Legge-Perthes, slipped capital epi- physis, trauma, congenital dysplasia, congenital dislocation, Otto pelvis, osteochondritis dissecans, osteochondromatosis, and ether types of arthritis are discussed* The author emphasizes prophylaxis in early treatment and mentions fusion, cup arthroplasty and obturator nerve resection* SAINT-MARC (14) suggests the division of treatment into two goals, re- lief of pain and Improvement of motion and he employs the usual methods of obtaining such. 188 In the palliative treatment of hip pain, denervation is suggested by RBYMOND (15) in those hips which are painful hut maintain a good range of mo- tion. He gives a review of the innervation of the hip joint with the tech- nique of denervation. LIEBOI/P et al (16) outline the results of 12 patients of advanced age who were operated upon for relief of pain in unilateral os- teoarthritis of the hip by obturator neurectomy. The anatomy and approach by the Inguinal extraperitoneal intrapelvic route are described. Follow-up maximum was ten months with relief in 11 of 12 cases. A technique is described by HARMON (1?) for the abdominal extraperi- toneal section of the obturator nerve at the level of the anterior superior iliac spine. The muscle splitting approach allows a bloodless, non-shocking operation with early ambulation. NIEBAUER and KING (18) report 20 hips in 15 patients denervated for pain, A selective neurectomy was done in relation to the sensory area involved. Section of the nerve to the quadratus femoris consistently relieved pain of the posterior hip. Intraabdominal section of the obturator was most satisfactory in patients with adductor tightness. Extensive dissection for the femoral branches gave unsatisfactory results, and resection of the anterior hip capsule is recommended as easier technical- ly and giving better results. COURT! and MARCHAL (19) present a technique for infiltration of the obturator nerve. The approaches are well explained and made understandable by five anatomic drawings. RATHCKB (20) presents l*f hips relieved of pain hy resection of the prae- sacral nerve* The results on follow-up in his series indicate a large peiv centage of relief* Operative risk is minimal* Duration of relief is some- what limited* Bladder capacity is increased very little and it is believed that this surgery is indicated in those conditions in which bladder pain is otherwise Incurable. FEPH and BMBS (21) describe antero—lateral chordot— «my in cases of painful arthritis of the hip Joint. In surgical treatment of the hip Gibson (22) presents his posterior ex- posure of the hip joint, which is rapid, almost bloodless and which results in minimal detachment of the muscles* This approach may he used for most op- erations of the hip* AUBIGNE (23) classifies cases into groups according to prognosis with treatment surgically. The prognosis may be good for post traumatic aseptic necrosis and congenital defects; medium for osteoarthritis and coxae seniles; and poor for progressive as rheumatoid arthritis or spondylitis. He divides surgery into minor operations - neurectomy, forage, capsulectomy and shelf operation - and major operations - arthrodesis and arthroplasty. GHARRY (2*0 suggests early surgery not only for pain but also for mo- bility for once muscles are degenerated, rehabilitation is more difficult* He discusses treatment from a general standpoint and suggests arthroplasty over arthrodesis where possible with or without interposition, according to the case. Vith destruction of the head, he advises prosthesis. The history of surgery for coxalgia since 1911 is reviewed by BLANKOFF (25). His is a somewhat confusing generalization (apparently referring to tuberculosis) which divides the treatment into four periods; early surgical intervention, operation only for abscess, arthrodesis and reconstructive. He feels that operation should be performed only when necessary, children 189 included, tout not below 14 years of age, and that true coxalgia will net heal without ankylosis. Hip Trauma Hip trauma is divided into two main groups: dislocations and fractures. Excerpts from the orthopedic literature of the 16th and l?th centuries de- scribing the reduction of hip dislocation are given by BROCKBANK and GRIFFITHS (26). In the first of a two-part article covering the literature, SEUIMAN (2?) discusses the types of dislocation, associated fractures, avascular ne- crosis and myositis ossificans. CONSTANTINI and BUTORI (28) report a case of bilateral traumatic dis- location of one week duration in a 46 year old male, easily reduced by closed method using light anesthesia and curare. THOMSEN (29) reports two cases of fracture and dislocation of the ace- tabulum. Case one had a primary open reduction with screw fixation and a four and one-half year follow-up showed satisfactory function. Case two was similar and was treated by traction with non-weight bearing. Six months la- ter patient was seen with increasing pain and subluxation. A reconstruction was done replacing the upper acetabulum by iliac crest graft. Infection and nonunion followed and a similar state existed five and one-half years later. On the basis of these cases primary open reduction is stressed. In fractures of the hip joint and pelvis, FRIDKIN and LAGUNOVA (30) discuss traumatic aseptic necrosis of the head of the femur. Abduction, adduction and rotational fractures of the neck of the femur are discussed by HAUCK (31)* The latter is emphasized as liable to not un- ite due to slight angulation. He points out that primary healing may occur and a stress fracture occur in the horizontal neck. The article is well il- lustrated. HENRY (32) gives a general review of hip fractures and their manage- ment without statistics or cases. Based on 98 cases of neck fractures treated by internal fixation with a nail, KURT (33) discusses nonunion. The author believes horizontal place- ment of the nail, producing great stress on all structures, contributed most often. No angle of less than 45° to the horizontal should bo used. Rein- sertion of the nail at a greater angle was sufficient to produce healing in several cases. The article is well illustrated and a curved nail is sug- gested in the discussion to remedy some of the problems. Reconstruction Surgery In general, there are four articles abstracted for reconstruction surg- ery. The operative procedures available for the arthritic hip joint and what each might accomplish is reviewed by STUCK (34). Emphasis is placed on pain as the dictating cause for all procedures, yet the specific operation varies with age, extent of destruction and the amount of disability to be produced. MEN1GAUX (35) discusses pseudarthrosls of the femoral neck, giving the 190 reason for pseudarthrosls, the examination of the patient with this condition, and the treatment which he divides Into two groupsj restoration and pallia- tire* To the author resection-arthroplasty and the intertrochanteric os- teotomy are the two procedures of choice, with arthrodesis and other recon- structions as the Colonna procedure as choices. Experience In several newer methods of treating osteoarthritis of the hip Is reviewed hy HEU’ET (36)* The intraartlcular Injection of lactic acid and procaine is useful if the joint space Is somewhat preserved and the hip is mobile. Belief may he obtained up to two years. Denervation is unsatis- factory If Incomplete, and the author has done no complete denervation. Ar- throdesis by a one-stage method with bone graft across the joint and nail fixation is recommended with supple backs and where arthrodesis is the pro- cedure of choice. Smith-Peteraen mould arthroplasty has been disappointing in the hands of the author but no figures are given. Excision of the femor- al head and neck has given good results for the author and is recommended in older individuals. HALBSTEIB (3?) gives a general talk on hip arthritis. Bo specific points are made. Under the heading of resection and osteotomy. TAYLOR (38) discusses the technique of operation for pseudarthrosls, with excision of head and neck of the femur and trimming of the acetabular rim. In 93 cases reviewed, 83 were classed as good results, two cases developed spurs on the femoral stump, five others were unsuccessful for varying reasons. It is thought to be most effective in ankylosing spondylitis and in patients over 60 years of age with disabling arthritis since It is done to relieve pain and restore mobility with limited function. OSBORNE and PAHRBI (39) present a study of the mechanics of the hip joint to determine how much postosteotomy pain relief is due to diminished wear and tear on the articular surfaces. Experimentally with skeletal parts and weights It was determined that the pressure across the hip joint varied with position - adduction, midposition, abduction, and sero with the osteo- tomy (McMurray). The position of the distal fragment was displaced with the inner angle Into the obturator extermus and upper surface against the trans- verse ligament of the acetabulum and the lesser trochanter against the Infer- ior Ischial ramus. There were 75 cases with 93 operations reviewed. Bo clinically successful case showed radiographic progress of the arthritis and several showed improved joint surfaces. Cases without a block to adduction or adequate displacement radio logically Improved on bearing but, those with weight bearing and continued pressure across the hip joint were unsat isfactory. MILCH (40) describes an operative procedure for arthritis and ankylo- sis of the hip. The neck is divided at Its base and the head and neck re- moved. The acetabulum is remodeled. The capsule is sutured over the neck stump. An osteotomy is done below the trochanter and fixed by a plate. The author presents one case and states he has employed it In ages 16-77 years and the patients are able to walk in six weeks. Patient follow-up Is not given. Poliowing observation In the clinic of Milch, CHAHRY (41) reports on 191 resection-angulation operation of the hip for arthritis* This consists of resection of the head and neck, capsular interposition, the introduction of a plate previously angled at 25° (Blount-Moore) into the greater trochanter, and an osteotomy at the base of the femoral dlaphysis* Resection insures mobility and angulation with osteotomy stability, and the plate allows early ambulation with crutches at three weeks and bearing at six weeks* He advises the use of the operation in Marie-Strumpells in place of prosthesis or arthroplasty and also as a means of reconstruction following failure of a prosthesis* Arthrodesis of the hip joint is the subject of eight articles abstracted in this chapter* STINCHPIEID and CAVALLARO (42) offer a follow-up study of arthrodesis of the hip joint, in which 11? patients were followed for four to 15 years after hip fusion* Nine over age 35 had only fair results, 19 pa- tients with suppurative arthritis showed improvement after fusion* 69 pa- tients with pain in the hip from osteoarthritis had relief with fusion* Ov- erall pseudarthrosis was 23 per cent, mortality rate was per cent, in- fection rate 6 per cent* Back pain was present in all groups in 31 per cent. The most normal gait obtained was with very slight adduction and no shorten- ing, an acceptable gait in neutral abduction-adduction without shortening and the poorest gait was with abduction without shortening* Intraarticular fusion with a bone graft and a nail was most certain of fusion* Elgfrt cases required osteotomy postfusion for unsatisfactory position* SISKA (43) describes his modification of arthrodesis for the treatment of destructive coxitis* He removes the greater trochanter and the femoral head, raises a lamella of bone from the ilium which rests on the cut surface of the trochanter* He reports his experience with this operation in 10 cases* KIEKALDY-NILLIS (44) presents a modification of the Brittain ischio- femoral fusion by approaching the region through an anterior Smith Petersen incision* Muscles, including the obturator ext emus, are divided or re- moved to explore the ischium* The graft is taken from the ilium and placed. BOTEIEEIRO (45) discusses the physiology of the hip, especially regard- ing Brittain-type arthrodesis with case reports* WEIL (46) debates the vir- tues of the extraarticular ischio-femoral arthrodesis versus the iliofemoral method* He advocates the Trumble approach over the Brittain stating there is less danger of hemorrhage and nerve lesions* CHAVES (4?) reviews the ischiofemoral arthrodeses with mention of the techniques of Trumble, Moragllono, Gultierrez, and Bosworth with emphasis on their success with the Brittain type. Six cases are presented, four of tu- berculosis and two of dislocation* Since 1942 DELITALA and PAIS (48) have treated 50 cases of congenital dislocation by open reduction and fusion. 45 cases were unilateral, four had subluxations on the opposite side, and one was a bilateral dislocation* The ages ranged from 12 to 40 with an average age of 18* The posterior-lat- eral approach between the tensor and gluteus medlus was used with tenotomy of adductors if needed. In 23 cases, the trochanter was transplanted as graft, in seven no graft was used, and in 20 a trans-artIcular graft was used. 36 cases were followed from one to seven years with uniformly good results in absence of pain* One had failure of bony ankylosis with no pain. The 192 author Indicates this procedure is to he applied In cases with unilateral high dislocation with good opposite hip and low hack. He also emphasises that the position of ankylosis must he exact, with a variation in abduction— adduction up to 10° in relation to the shortening. FABIAN (h9) discusses Tavernier’s operation of arthrosis of the hip. He found that in every case, even during superficial anesthesia, there is considerable spasm of the adductors. This is the reason for the painful ex- pression. He modified the Tavernier operation in such a manner that after the resection of the sensitive posterior branch he also partly resected the anterior branch (after Stoffel). This is extremely important because the anterior branch also contains sensitive fibers. He refrained from the Tru- chet operation which requires a second stage resection of the branch to the M. quadratus fem. n. carre crural. Access is from the trlgonum Scarpae with the electrical Identification of the branches. He does not agree with to- tal exhairesis because this causes disturbances in walking later. This op- eration is indicated in elderly patients with a simple disease process, where a major plastic operation is not necessary. These patients are satis- fied if they can be assured of their walking ability for a few years. In 26 cases, all showed Immediate considerable progress. Two patients who were unable to put their shoes on before operation were able to do knee-bends ten days after the operation. In four cases pain recurred a year after the op- eration but was not nearly so severe as before, and mobility was quite good. In the remaining cases the good results were maintained. The oldest case had a two year follow-up. Two cases were without benefit. The author is convinced from operations on 85 cases up to 1950 that dissatisfied cases were in consequence of not finding the n. ebturatorius accessorius. Arthroplasty is the subject of 11 articles abstracted. A comparison of the Smith-Petersen and Judet techniques is made by CHIGOT (50). He fol- lows the usual principles and indications for his choice of procedure and cautions the use of the Judet approach when extensive acetabular surgery is indicated. SALMON (51) presents two cases of congenital dislocation of the hip on whom arthroplasty was done one year before, by different techniques. Author advocates open reduction only when closed techniques are unsatisfactory and the arthrogram is positive. AUBIGNB (52) reflects upon the indications for arthroplasty with inert interposition in arthritis deformans of the hip. He suggests vltallium mold for established cases with acetabular damage and synovial thickening. Other- wise no choice exists. In younger persons where a long neck exists the in- sertion of a cup maintains length which might be useful later in a fusion. In bilateral involvement, author suggests arthroplasty three weeks apart, unless bedridden for a long period, then fusion is necessary on one side. The author emphasizes the necessity of suitable selection of cases for mus- culature, lack of deformity and good technical surgery. A serious postoper- ative reeducation of the patient is necessary for satisfactory results. KINI and NAIDU (53) report one case in which they did a vltallium mold arthroplasty which was followed for four months. CHEYNEL (5*0 brings a preliminary report of a rather less expensive cup which Is of a special type and adapts Itself more closely to the head of the femur. Author feels that from a recent report from a well known histologist the revascularization of the femoral neck with following regeneration in a patient of 50 years of age with no or little capsule, synovial membrane and round ligament, is quite an exception. He gives in detail the metals used. JDDBT and JHD0T (55) give a description of the prosthesis and technique as employed hy them for osteoarthritis, ununited fracture of the femoral neck, non-tuberculous ankylosis of the hip and old dislocation of the hip* Ho cas- es or follov-up are provided* SICARD (56) reports a three week follow-up of a 64 year old woman with a Judet prosthesis in whom he did a lipiodol injection Into the new articula- tion, He feels that this increases the postoperative analgesia and eases movements. RICHAED (57) used a different technique in four cases of congenital dislocation of the hip treated with acrylic femoral head. The operative tech- niques which differ in each case are very briefly discussed and are not very evident. AUBIGHE (58) presents 13 cases of high congenital dislocations treated in the adult with modern arthroplasty. He concluded that arthroplasty will bring the head down to its normal level when a new acetabulum has been made, will bring fair, though far from normal mobility, will increase the stability and decreases the limp and will alleviate and possibly eliminate pain. How- ever, there should be a very cautious and careful preoperative examination before any surgery is indicated or undertaken. JUDET (59) discusses a film on arthroplasty of the hip in congenital dislocation. He disagrees on the following points: the acetabulum should be made at its normal level, not at the level of the neo-acetabulum, the sim- plicity of the technique presented by Judet should not open the way to ex- tensive hip surgery by the Inexperienced surgeon, and finally, the sectioning of the femorocutaneous nerve in the Smith-Petersen approach. He emphasizes the need for great caution in deciding to use arthroplasty. Arthroplasty of the hip with acrylic by SALMON et al (60) is a rather confused critique based on presented x-rays. Among other methods of treatment in reconstruction surgery for hip joint pain is one of coxarthritis treated by capsulectomy reported by GUILLE- MIHET (6l), He states that degenerative changes In the joint itself may be a contraindication for capsulectomy, as the patient might not be relieved of pain by this procedure. Only 52 per cent of his 15 patients were more or less relieved following capsulectomy. In no case was the function improved and in some cases it was impaired. He concludes that capsulectomy will prob- ably be only a step in more radical surgery for coxarthritis. Pelvis In studying the anatomy of the pelvis ROWE (63) examined 1539 specimens and three showed a similar anatomical variation consisting of loss of contin- uity between the superior articular process and the pedicle of the first sac- 194 ral segment* In two of these spina bifida involved the same neural arch and thus one-half the arch was free of any bony connection. The normal pattern of ossification of the neural arch is for one ossification center to appear in the cartilage between the superior and inferior articular process of each half of the neural arch and to spread from there posteriorly to meet in the spinous process and to meet anteriorly at the neurocentral synchondrosis* This anomaly could be explained by either division of the center or the ap- pearance of two separate centers. 460 specimens were studied by SCHULTZ (64) to determine if secondary sex differences in the pelvis are limited to man. In all adult primates the ischium length is larger in males than females, but pubic length and pelvic inlet breadth are larger in the adult females than males. Measurements in- dicate there is no definite proportionality between the size of the pelvis and the size of the fetus. Horizontal symphysis as a causative factor in abnormal deliveries is discussed by BRAULT and DUBOIS (65)* DEMOULIN (66) reports a case of a male child born with absence of the abdominal wall and iliac bone on the right. DBUCHER (6?) writes on the value of the sacral approach in surgery of the pelvis minor. He stresses the sacral or confirmed abdomlno-sacral approach to the colon, rectum, sacral plexi or lower ureters. This is not orthopedic. According to THIELE (68) cocc.vgodynia is caused by direct trauma and by muscle spasm secondary to focal infection. It may be cured by massage of the spactic muscles, together with removal of foci of Infection, when neces- sary or desirable. In rare cases of osteoporosis, osteomyelitis, or frac- ture surgical excision may be necessary. HAGrQART and SCHULER (69) and DESSE (70) review briefly the conserva- tive methods'of treatment, as manipulation, correction of posture, proper use of chairs, etc. 180 cases of rectal and low back pain were studied by SCHAPIRO (71) and are grouped according to their etiology and symptomatology. All groups showed tenderness or spasm of levator anl, coccygeus, and piriformis muscles on one or both sides. In group representing orthopedic conditions best treat- ment was obtained by orthopedic procedures. Manipulation of coccyx through rectum was effective in some cases. When no orthopedic condition existed, most were cured by rectal diathermy or massage. This treatment was effective for all groups. Digital examination of rectum was the most important diag- nostic procedure. In tumors of the pelvis, NELSON (72) describes a case of extramammary Paget’s disease of ano-coccygeo-sacro-gluteii areas. In trauma to the pelvis HORANYI (73) discusses dislocations in the pel- vic girdle. He recognizes eight things that may happen: (a) lumbosacral spine from pelvis (spondylolisthesis), (b) unilateral luxation of pelvis, (c) bilateral luxation, (d) luxation of the ilium, (e) luxation of the sa- crum, (f) luxation of the coccyx, (g) symphyeolysis. 195 BIBLIOGRAPHY 1. Saxl, A.: Insufficiency and defects of the hip Joint, Wien, kiln, Wschr., 62; 355-7, May 19, 1950 2. Seze, S. de, and Durieu, J.: Remarks and hypotheses on the role of vascular factors in the pathogenesis of arthroses and of coxarthrosis in particular: attempt at classification and pathogenic interpretation of hip Joint diseases. Rev* rhumat., 1?: 215-8, May 1950 3* Maurer, H* J*; Roentgen diagnosis of osteochondritis deformans Juven- ilis coxae at an early stage, Portsch. Rontgenstrahl*, 72; 739-*K)» Apr 1950 if* Klopper, P.; Roentgenography of hip Joint dislocation due to disten~ tion, Portsch. Rontgenstrahl*, 735 357-61, Juno 1950 5* Prancon, P*, and Perles, L*; The overhang sign and the screw sign in the early diagnosis of coxarthrltis, Acta physiother. rheumat* helg*, 5: 87-9. Mar-Apr 1950 6* Prancon, P*; How does coxarthritis begin?, Medecin fr*, 10; 136, May 10, 1950 7* Harris, C*: Orientation hy radiography for the management of coxitis, J* radiol. electr*, 31: 37 51 1950 8* Porestier, J*: Examination of the hip in rheumatology, Rhumatologio, —: 69-70, Mar-Apr 1950 9* Prancon, P.; Arthritis of the hip, Acta physiother. rheumat* belg*, 5: Jan-Peb 1950 10. Prancon, P.; Coxarthritis, Acta physiother. rheumat. belg., 5* 69-* 86, Mar-Apr 1950 11* Prancon, P.; The limits and contents of coxarthritis, Rhumatologio, —s Mar-Apr 1950 12. Pranclllon, M, R.; Treatment of osteochondrosis deformans Juvenilis coxae, Zschr. Orthop., 79? 263-268, 1950 13* Nagel, L. C.; Painful hips in adults, J. Am. Osteopath. Ass., **9: 218-20, Dec 19^9 14. Saint-Marc; Medical treatment of coxarthrosis, Rhumatologie, —; 53- 5, Mar-Apr 1950 15. Reymond, J. C.; Denervation of the coxarthritic hip, J. prat., Far., 63; 583-8, Nov 10, 19^9 16. Llebolt, P. L., Beal, J. M«, and Speer, D. S.s Obturator neurectomy for painful hip. Am. J. Surg., 79? 427-31, Mar 1950 196 17* Harmon, P. H,: Transabdominal extraperitoneal section of the obturator nerve trunk, J. Heurosurg., 7: 233-5, May 1950 18. Niebauer, J. J., and King, D.: A consideration of the denervation op- eration for the relief of hip pain, Stanford M, ‘Bull., 75 149-51, Nov 1949 19. Coorty, A,, and Marchal, G,: Technique of infiltration of the obtur- ator nerve, Presse, med,, 57: 1093, Hov 26, 1949 20. Rathcke, L,; Relief of pain hy resection of the praesacral nerve, Chlrurg., 21: 389-94, June 1950 21. Petr, R., and Benes, V,: Anterolateral chordotomy in cases of painful arthritis of the hip joint, Acta chir. orthop. traura. cech., 17: 162- 6, 1950 22. Gihson, A,; Posterior exposure of the hip joint, J. Bone Surg., 32 B: 183-6, May 1950 23« Merle d'Aubigne, R.: Surgical treatment of coxarthritis, Sem. hop.. Par., 26: 2665-9, July 26, 1950 24. Gharry, R.: Principles which should guide the doctor towards surgery in coxarthrosis, Rhumatologie, —: 56-64, Mar-Apr 1950 25* Blankoff, B.; Statistics of surgery for coxalgia: 1925-1950, Scalpel, Brux., 103: 769-87, Aug 5, 1950 26. Brockbank, W,, and Griffiths, D, L.: Luxations of the hip, J. Bone Surg., 32 B; 274-8, May 1950 27* Shulman, S,; Traumatic dislocation of the hip joint; a collective re- view of the complications and sequelae, S, Afr. M, J., 23: 1025-1030, Dec 17, 19^9 28. Constantini, and Butori: Bilateral traumatic dislocation of one week duration; easily reduced by using curare, Afrique fr. chir., —: 238, Nov-nD ec 19^9 29* Thomsen, W.: Surgical restoration of the traumatic loss of substance in the acetabulum, Arch. Klin. Chir. (Langenbeck's), 264: 482-8, Apr 11, 1950 30. Fridkin, V, I,, and Lagunova, I. G.: Traumatic aseptic necrosis of the head of the femur, 7est. khir., 70: 39-43, 1950 31. Hauck, G. J.: Apparent cure, bone atrophy and pseudarthrosis in medial fracture of the neck of the femur, Arch, Klin, Chir, (I&ngenbec^s), 264 : 531-46, Apr 11, 1950 32. Henry, M. 0.: Advances in treatment of fractures of the hip, S. Dako- ta J. M., 2: 319-23, Hov 1949 197 33. Kurt, E.: Hemote results in nailing of the neck of the femur. Arch. Klin, Chir. (Langenbeck's), 264: 552-66, Apr 11, 1950 34. Stuck, W. G.: The surgical treatment of degenerative arthritis of the hip. South. M. J., 42: 1021-9, Dec 1949 35. Menegaux, G.i Pseudarthrosis of the femoral neck, Press© mod., 575 1156-B, Dec 14, 1949 36. Helfet, A. J.: A consideration of recent surgery of osteoarthritis of the hip joint, S. Afr. M. J., 24: 637-42, July 22, 1950 37. Falhsteln, B. M.: Arthritic derangements of the hip, J. M. Soc. R. Jersey, 47: 64-6, Peh 1950 38. Taylor, R. G.: Pseudarthrosis of the hip joint, J. Bone Surg., 32 B: 161-5, May 1950 39* Oshorne, 6. V., and Pahrnl, V, H,: Oblique displacement osteotomy for osteoarthritis of the hip joint, J. Bone Surg,, 32 B: 148-60, May 1950 40, Milch, H.: The resection-angulation operation for arthritis and anky- losis of the hip, J. Internet, Coll. Surgeons, 13: 750-6, June 1950 41, Gharry, M. R.j Resection-angulation operation for arthritis of the hip, Dull. Soc. chir.. Par., 39: 165-77, Oct 21-Rov 4, 1949 42, Stinchfield, P. E,, and Cavallaro, V, U.: Arthrodesis of the hip joint; a follow-up study, J. Bone Surg., 32 A: 48-58, Jan 1950 43* Siska, K.: Author’s modification of arthrodesis for the treatment of destructive Bratisl. lek, llsty, 30: 105-12, Peh 1950 44. Klrbaldy-Vlllls, V. H.: Ischiofemoral arthrodesis of the hip in tu- berculosis; an anterior approach, J. Bone Surg,, 32 B: 187-92, May 1950 45. Eotelheiro, J.: Brittain-type arthrodesis. Gas. med, port., 2: 779- 84, 1949 46. Veil, S,: Ischiofemoral extra-articular arthrodesis, Zschr. Orthop., ' 79: 389-92. 1950 47* Chaves, D, A,: Ischiofemoral arthrodesis of the British type, Med. clr. farm., —: 243-8, Juno 1950 48. Delitala, P., and Pais, C.: Delayed results in 50 cases of reduction- arthrodesis in inveterate unilateral congenital dislocation of the hip. Arch, ortop., 63: 161-3, Apr-Jun 1950 49. Fabian, P.: Tavernier’s operation of arthrosis of the hip. Gas. lek. cesk., 89: 694-6, June 16, 1950 50. Chigot, P, L.: Prostheses for hip arthroplasties, Suppl, Paris mod.. 198 2: 141-4, Nov-Dec 1949 51* Salmon: Congenital dislocation of the hip; arthroplasty, Marseille chir., 2: 301-2, Mar-Apr 1950 52* Merle d'Aubigne, R.: Indications for arthroplasty with inert inter- position in arthritis deformans of the hip, Rhomatologie, —; 65-8, Mar-Apr 1950 53* Kini, M. G,, and Raida, I. C.: Cap arthroplasty in hip Joint sorgery, Ind. M. Gaz., 85: 19-20, Jan 1950 54. Cheynel, J.; Examination of cap arthroplasty of the hip; form and pol- ishing the metal cup. Rev. orthrop., 36: 5**—7, Jan-Mar 1950 55* Jodet, J., and Judet, R.: The use of an artificial femoral head for arthroplasty of the hip Joint, J. Bone Surg., 32 B: 166-73* May 1950 56. Sicard, A.: Reconstruction of the femoral head with an ossacryl pros- thesis smeared with llpiodol; results after three weeks, Mem. Acc-d, chir,. Par,, 76: 56, Jan 11, 18, 19, 1950 57* Richard, A.: Congenital dislocation of the hip treated hy surgical re- duction and replacement of the femoral head with ossacryl, Mem. Acad, chir., Par., 76: 301, Peh 22-Mar 1, 1950 58. Merle d’Aubigne, R.; Surgical reposition with arthroplasty in the treatment of inveterate high congenital dislocations in adults, Mem. Acad, chir., Par., 76: 347-52, Mar 8-15, 1950 59« Judet, R.: Resection-reconstruction of the hip in inveterate congeni- tal dislocation in adults, Mem, Acad, chir.. Par., 76; 356-7, Mar 8- 15. 1950 60. Salmon, Bouyala, Corniti, and Bellon: Arthroplasty of the hip with a- crylic prosthesis, Marseille chir., 2: 271-3* Mar-Apr 1950 61. Guilleminet: Capsulectomy in the treatment of coxarthritis, Mem. Acad, chir., Par., 76: 128-38, Jan 11, 18, 19, 1950 62. Guilleminet, M., and Geay: A 14 day result of a capsulectomy for os- teoarthritis of the hip, Lyon chir., 44: Nov-Dee 1949 63. Rowe, G. G.: Anomalous vertebrae from the lumbosacral column of man, Anat. Rec., 107: 171-9, June 1950 64. Schultz, A, H,: Sex differences in the pelves of primates, Am. J. Phys. Anthrop., 7: 401-23, Sept 1949 65. Brault, P., and Dubois, J.: Pelvis with horizontal symphysis, Gyn. obst., 49: 307-11, 1950 66. Demoulin, P.: Right iliac agenesia with lumbo-crural eventration, Acta paediat. belg., 4: 59-62, 1950 199 6?* Boucher, P.: Value of the sacral approach in surgery of the pelvis minor, Schweiz, mod, Vschr., 80: 895-7» Aug 26, 1950 68. Thiele, G. H.: Coccygodynia; the mechanism of its production and its relationship to anorectal disease, Am. J. Surg., 79! 110-6, Jan 1950 69* Eaggart, G. E., and Schuler, F. B.r The management of coccygodynia, Surg. Clin. F. America, 3°: 9^5-9» June 1950 70. Desse, G.: Coccygodynia, Medecin, 10: 1*K), May 10, 1950 71* Schapiro, S.: Low hack and rectal pain from an orthopedic and proc- tologic viewpoint; with a review of 180 cases. Am. J. Surg., 79s 117- 28, Jan 1950 72. Kelson, T. P.: Extraraammary Paget’s disease of ano-coccygeo-sacro- gluteil areas. Am. J. Surg., 79! 196, Jan 1950 73* Eoranyi, J.: Dislocations in the pelvic girdle, Orv. hetil., 9l! 855- 7. July 2, 1950 200 CHAPTER XIV KNEE JOINT By Thomas S, Barron, It. Colonel, MC U. S. Army Hospital Camp Roberts, California Assisted By Wayne W. Glas, Captain, MC I. Knee joint as a whole A. Anatomical B. Effusion and infection C. New growths D. Surgical treatment B. Reconstruction surgery II. Menisci A. Discoid menisci B. Injuries III. Synovia IV. Ligaments V. Patella A. General aspects B. Dislocation and fracture C. Chondromalacia VI. Quadriceps VII. Miscellaneous The Knee Joint as a Whole Of the *0 articles abstracted for this chapter, only four deal with the anatomical aspects of the knee joint. Articles on the anatomy of the knee Include a 52 page monograph on prenatal development of the knee by GRAY and GARDNER (l). The knee Joints were studied in a series of human em- bryos and fetuses ranging in age from six weeks to term. The unchondrified blastema between the tibial and femoral cartilages becomes thinned to form a disc or interzone by seven and one-half weeks. This serves as a growth center for cartilage and in its middle portion, cavitation takes place. As the joint increases in size, and before a fibrous capsule is present, adja- cent mesenchyme becomes intraarticular in position. The menisci and cru- ciate ligaments arise from the characteristically vascular synovial mesen- 201 chyme and appear first at ahoat eight weeks of development. Vascularization of the cartilaginous epiphyses begins by 12 weeks, and ossification centers appear in them by term. The individual cavities enlarge, coalesce and form a single cavity by l*f weeks or soon thereafter. A fabella, first present in a specimen of 14 weeks, occurred inconstantly in the older specimens. The superficial prepatellar bursa appeared for the first time at 11 weeks. PRICE (2) writes on the juvenile posture of the legs and knees. In the normal development of posture of the legs there is a varold phase to the age of two years and a valgoid phase to six years. Abnormal varoid phases up to two years should be treated by Denis Browne splints. After two years osteoclasis is recommended. Knock knee of moderate degree responds to one- fourth inch medial wedge to heel only. Splints are not advocated until age of five, then the use of a Thomas knock knee brace Is recommended. Very few children come to osteotomy for knock knee. Older patients may require it. PEDERSEN (3) studied the ossicles of the semilunar cartilages of ro- dents and found them constantly present in the anterior portions of the men- isci and frequently in the posterior portions as well. Reports on the ossi- fication of the semilunar cartilages in man were reviewed and. the reason for such ossification discussed. It is felt that a completely intrameniscal os- sicle in man may bo a vestigal structure but that it is of normal occurrence in rodents. GARDNER et al W determine that articular afferent fibers from knee joint synapse with internuncial neurons shortly after entering spinal cord and continue rostrally in ipsilateral dorsi funiculi to the medulla oblong- ata. In effusion and infection of the knee joint BODREL (5) gives a de- tailed listing of all known causes for swelling of the knee joint and the specific treatment when available. No new concepts were advanced. Three papers are discussed by WEISSENBACH and FRAN CON (6). They cov- ered hydrarthrosis of gout which can show itself in three ways as the first sign of illness, alternating with sore inf lammed great metatarsophalangeal joint and gout superimposed on hypertrophic arthritis caused by gout. The second paper discussed the various phases of rheumatoid arthritis of the knee. The third paper concerned postmenopausal arthritis in female and hy- pertrophic arthritis in male. A series of abstracts are presented in REV. RHUMAT. (7) covering stud- ies on hydrarthrosis of the knee. Causes given were; (a) gout, (b) degen- erative osteoarthritis, (c) tumors, (d) arthropathies (luetic and syringo- myelia), (©) hormonal origin (hyperfollicular stimulating hormone, thyroid dysfunction, eunuchism), (f) traumatic and mlcrotrauoatic (fractures, tears of menisci, tears of ligaments), (g) faulty weight bearing alignment of knees, (h) congenital syphilis, (i) lymphogranuloma Inguinale, (j) rheumatic fever, (k) gonorrheal arthritis, and (l) hypertrophic arthritis. BLANKOPF (8) presents 19 cases of early tuberculosis of the knee diag- nosed first by x-ray and later confirmed by laboratory etcdles inclrdlng pathological slides. Earliest x-ray signs are marginal decalcificatton of 202 the condyles, plateaus, posterior part of internal tiblal plateau and tihial crest. This decalcification hites toward the depth of the condyles. Author suggests that these early x-ray findings should influence a physician to treat these knees as tuberculosis. A case of pseudomonas aeruginosa pyoarthrosis of the knee treated suc- cessfully with streptomycin parentally and locally into the joint is reported hy CARMSALE and WAISMAN (9). In considering new growths in the knee joint a case of osteocartilag- inous loose body is reported by BASTIBM (10). It was five and one-half cen- timeters in longest diameter and was removed by vertical sectioning of the patella with successful results. SATANOVSKY (ll) reports a case of giant cell granuloma of the knee. This tumor involved the fat pad ligaments, the infrapatella ligament and the lateral semilunar cartilage. Microscopically the tumor presented small spher ical masses. These were bluish white, resembling cartilaginous tissue. Some areas had hemosiderin deposits with peripheral redness, and some had small hard vegetations. Microscopic picture was sclerosis of fat pad, old organ- ized hematoma and lobulation with infolding of hyperplastic synovium. Turn- er tissue consisted of young connective tissue cells with little protoplasm and big, well colored, nucleus and small nucleolus. Some hyalin degenera- tion was present. Authors feel this tumor is of a granulomatous rather than neoplastic origin. SARPYEMER and AKAD (12) report a case of synovial chondromatosis of the knee joint containing 2000 nodules treated by complete synovectomy. Surgery has been recommended for many conditions of the knee joint. MARCONI (13) discusses the importance of arthrotomy of the knee for differ- ential diagnostic purposes when the x-ray and other methods do not give the diagnosis. KELIKAN (1*0 discusses the anatomy of the knee joint and the indica- tions for surgery. Conditions listed are: drainage for pyogenic arthritis; fusion for tuberculosis, flail joint, Charcot joint, and advanced painful arthritis; cartilage Injuries; synovial out-pouchings; osteochondritis dis- secans; osteocartilaginous loose bodies; chondromalacia of patella; patella fractures; depressed plateau fractures; pigmented villonodular synovitis; subsynovial tumors;and Thompson stripping for quadriceps adhesions. BEARZY (15) reviews internal derangements of the knee joint, with their diagnosis and treatment. BUIRGE (16) makes statements on a study of 283 patients admitted to Oliver General Hospital, during an 11 month period in He stresses the importance of quadriceps exercises pre and postoperatively. The spring scale muscle test was advocated for determining quadriceps muscle power recovery following arthrotomy and knee joint injury. Author had no reliable method of determining location of tear of meniscus. He recommended excision of ap- parently normal medial meniscus, when no tear was found, to prevent missing a posterior tear. In reconstruction surgery of the knee SEARMBORG (1?) presents the re- sults of cases of knee resections, including tuberculous and non-tubercu- lous types of infection. The indications, technique and results are presented The technique of nylon arthroplasty of the knee is described by KUHNS and POTTER (18). A median parapatella incision was used; condyles of femur were rounded off. A trough was made in the tibia and the menisci and the cruciate ligaments were excised. The patella was thinned and medial and lat- eral collaterals were saved. Nylon was sutured over all surfaces including suprapatella pouch. Postoperative care was discussed. Authors state that useful range of painless motion can be obtained in knees destroyed by chronic arthritis. Many of their patients had 90° motion. COSTANTINI (19) advocates the use of a tibial autogenous bone graft in the intramedullary cavities of femur and tibia in arthrodesis of the knee to prevent displacement while awaiting fusion. Arthrodesis of the knee with the use of a Kuntscher nail is described by CASTILLO ODENA (20). Menisci JEANNOPOULOS (21) reports a series of 21 discoid menisci removed from 18 patients in a 15 year period at New York Orthopedic Hospital. An unusual case of "both menisci in one knee being discoid was presented. per cent of these menisci showed either central mucoid degeneration or peripheral cysts. X-ray findings in some cases consisted of widening the lateral joint space and occasionally hypoplasia of lateral femoral condyle# BURMAN and NEUSTADT (22) believe that high flbular head is a regressive anomaly resulting from a developmental failure to exclude it from the knee joint. The embryology of knee joint cartilages and proximal fibular head were discussed. Cases were presented which demonstrate: discoid meniscus without tear give disability; borderline cases in which the condition Is be- tween snapping and locking; and cases of locked knee because of tear of dis- coid cartilage. The roentgenologic signs of discoid meniscus are flattening of the external femoral condyle, widening of lateral joint space and high fi- bular head. The discoid meniscus and tear can sometimes be seen. Injuries to the menisci are quite common. BONAR (23) reviews 200 men- iscectomies and the various factors influencing the postoperative disability period. The greatest single factor is age, A delay of up to six months be- tween injury and operation has no obvious influence on the disability time. The disability period is not significantly affected by the nature of the in- dividual's work. The results of meniscectomy in a joint with severe osteo- arthritis are very discouraging. Minor degrees of arthritic change are not a contraindication to operation. HEMBROW et al review the operative treatment of 140 servicemen with internal derangements of the knee. SCAREI and GAMBI3R (25,26) in two similar papers make a report on a series of cases treated by meniscectomy. 40,9 per cent resulted in arthritic changes, ?4- per cent showed reduction on intra-articular space, 57*9 per cent 204 of cases had almost perfect functional results, 28.8 per cent of the cases were satisfactory and 11,1 per cent received doubtful beneficial results from surgery. Cases were followed seven to ten years minimum. Authors feel that total meniscectomy gave the best results. Synovia A report on 36 partial synovectomies for chronic polyarthritis and oth- er cases with unknown exudate is presented by MAGNUSON {27)* Final results are presented. PIPKIN (28) discusses the fact that the suprapatellar space of the knee joint is developed emhrylogically from two structures. These are the supra- patellar "bursa and the suprapatellar portion of the knee joint. A suprapatel- lar plica can he demonstrated hy pneumoarthrography in 78 per cent of the ad- ult knees studied. This plica represents a remnant of the mesodermal layer separating suprapatellar "bursa and knee joint proper. In the majority of in- stances this plica has various sized defects permitting free communication between suprapatellar "bursa and knee Joint. A case of calcification of su- prapatellar plica treated with surgical excision was presented. A second case of hyalinization of the suprapatellar plica which was treated hy partial synovectomy was also presented. Fibrosis, hyalinization, or calcification of the suprapatellar plica mechanically interfere with the extensor apparatus producing a syndrome of pseudolocking, pain, and chronic effusion which must he differentiated from other intra-articular disabilities. Ligaments McCONVILLE (29) states that collateral ligament tears which do not res- pond to four weeks immobilization in plaster should be repaired: imbrication to tensor fascia lata used to repair lateral collateral ligament tears, Un- interruptel gracilis tendon graft was used to replace tear of medial collat- eral ligament. 16 cases were reported with stable knee joints resulting, ten lateral ligaments were repaired and six medial ligaments were repaired. Patella Two articles in this category were on the general aspects of the pa- tella. CAVE and ROWE (30) recommend that chondromalacia of the patella be removed surgically when causing symptoms and findings of derangement. Pa- tellaplasty should be done in hypertrophic arthritic patella. This consis- ted of using a saw to remove articular portion of patella and covering raw bony surface with flap from infrapatella fat pad. Torn cartilages and loose bodies should be removed. Authors condemn patellectomy as treatment of chon- dromalacia and hypertrophic arthritis, 18 cases were reported. Dr. Paul B, Magnuson of Chicago suggested complete joint debridement. Dr. Harry C. Blair of Portland felt that surgical excision of chondromalacia of patella was suf- ficient. Indications for total or partial patellectomy enumerated by GUILLE- MINST (31) are as follows: (a) closed fractures, (b) comminuted and trans- verse, (c) old fractures with fibrous callus and pathologic fractures of a- taxics and diabetics, (d) early compound fractures and occasional old com- pound fracture in face of infection, (e) osteomyelitis of patella, (f) early 205 tuberculosis of patella, (g) tumors of patella, (h) degenerative arthritis, (i) posttraumatic arthritis, (j) recurrent dislocations. There are two articles on dislocation and fracture. GOODE (32) pre- sents a case of osteochondral fracture of the medial one-half of the articu- lar surface of the patella successfully treated hy patellectomy and removal of a fragment from the lateral side of the knee. Two previous cases were re- ported in the English literature. Injury is prohahly produced hy a glancing blow striking the patella on the medial aspect. PRUVOT (33) reports two cases of habitual dislocation of the patella. SPRAY and G-HORMLEY (3*0 report on 50 cases of chondromalacia of the pa- tella, and the following points were brought out: age varies from 1*4—62 years, with an average of 39; sex nearly equal; trauma to patella in per cent; incomplete locking present in 32 per cent; difficulty in climbing steps pre- sent in 24 per cent; knee joint effusion present in 56 per cent; suprapatel- la crepitation present in 74 per cent; patella tenderness present in 14 per cent; and marginal osteophy es of patella most common x-ray finding. COSTE et al (35) discuss chondromalacia of the patella. PROCHAZKA (36) differentiates osteochondritis of the patella into two types: prepubertial and pubertial. WOLE (37) discusses the history and reviews previously recorded cases of Larsen-Johanssen disease; the possible etiology, pathology and clinical features, with a form of treatment suggested. Quadriceps SCUDERI and SCHREY (38) review 14 quadriceps tendon ruptures. Diag- nostic criteria were discussed. Author advocates early recognition and prompt suture with Bunnell pullout wire sutures and with interrupted 00 chro- mic catgut sutures placed in x manner. Early suture precludes fibrotic con- tracture of quadriceps mechanism and gives much better range of motion. Late repairs require Codivilla lengthening of quadriceps mechanism before suture can be accomplished. MICHOTTE (39) presents a case of bilateral rupture of suprapatellar tendons successfully repaired 11 months following trauma. A case of rupture of the anterior rectus femoris tendon only with the rest of the quadriceps mechanism intact is presented by SARLIR (4o). Injury was incurred by forceful extension of the quadriceps muscle. The tendon was sutured with nonabsorbable suture and functional recovery was excellent. Author comments on the small number of reported cases of partial tear of quad- riceps as compared to the large number of total tears in the literature. Miscellaneous CAPECCHI (4l) discusses the relation of the glenna constant to arthri- tis of the knee. The femoral neck should form a right angle with the long- itudinal axis of calcaneus. Weak feet lead to a valgus deformity which in- 206 terfers with feraoral-calcaneal angle. This results in abnormal rotation at knee to correct this altered angle. Treatment should he directed to correct- ing the femoral-calcaneal angel rather than treating knees locally. LOHE (42) reports increased stability in flail knees produced by doing osteotomy of proximal end of tibia and tilting the tibial plateau backward, MOFFATT (43) placed patients prone on a table flexing knee to 90° and rotating medially and laterally while exerting strong traction in flexion and extension to free impacted loose bodies in the joint. 207 BIBLIOGRAPHY 1. Gray, 0. j, t and Gardner, E.: Prenatal development of the human knee and superior tibiofibular joints. Am. J. Anat., 86: 235-87, Mar 1950 2. Price, E. E.: Juvenile posture of the legs and knees, Med. J. Austra- lia, 2: 589-91, Nov 22, 1949 3. Pedersen, H. B.: The ossicles of the semilunar cartilages of rodents, Anat. Rec., 105: 1-9, Sept 1949 4. Gardner, E., Latimer, F., and Stilwell, D.: Central connections for afferent fibers from the knee joint of the cat. Am. J. Physiol., 159: 195-8, Nov 1949 5* Bourel, M.: Treatment cf hydarthrosis, Gaz. med. France, 57: 403-8, Apr 1950 6. Weissenbach, R, J,, and Francon, F.s Recent conference at Dax on non- tuberculous hydarthrosis of the knee, Bull, med,. Par., 64: 177-81, Apr 15. 1950 7» Study of non-tuberculous hydrarthrosis of the knee. Rev. rhumat., Par., 17: 85-9, Feb 1950 8. Blankoff, B,: Nineteen cases of white tumor of the knee; early case finding, Acta orthop. belg., 16: 315-26, June 1950 9* Camsale, P. L., and Waisman, R. C,: A rare case of Bacilus pyocyan— eus (Pseudomonas aeruginosa) pyoarthrosis of the knee, Surgery, 27: 939-41, June 1950 10. Bastion, P.: Voluminous solitary osteochondroma of the articulation of the knee, Lille chir., 5: 132-3, May-June 1950 11. Satanowsky, s.: Giant cell granuloma of the adipose ligament of the knee. Rev. As. med. argent., 64: 274-5, June 15-30, 1950 12. Sarpyener, M, A., and Akad, N.; Synovial chondroraata in the knee joint, Turk tip cemiyeti mecmuasi, 16: 205-10, Apr 1950 13# Marconi, S,: Arthrotomy in the diagnosis of chronic arthrosynovitis of the knee, Arch, ortop, 63: 130-1, Apr-Jun 1950 14. Kelikian, H,: Surgical conditions of the knee, Indust. M., 19: 72-4, Feb 1950 15* Bearzy, H. J.; Internal derangements of the knee Joint; their diag- nosis and treatment, Arch. Phys. M,, 31: 162-9, Mar 1950 * 16. Buirge, R. E.: Some disabilities of the knee; a statistical survey. Surgery, 26: 770-6, Nov 1949 208 17. Skarenborg, H,: On resection of the knee, Acta orthop, scand., 19: 312-25, 1949 18* Kuhns, J. G-,, and Potter, T. A,; Nylon arthroplasty of the knee joint in chronic arthritis, Surg. Gyn. Obst., 91: 351-62, Sept 1950 19, Costantini, H.: Bone grafting in femur and tibia after resection of the knee, Afrique fr. chir,, —: 234, Fov-Bec 1949 20, Castillo Odena, !•: Arthrodesis of the knee with use of a Kuntscher nail, Eol. Acad, argent, cir., 33: 717, Sept 28, 1949 21. Jeannopoulos, C, L.1 Observations on discoid menisci, J. Bone Surg., 32 A: 649-52. July 1950 22. Eurman, M., and Feustadt, E,: Torn discoid meniscus; association of discoid meniscus with congenitally high position of the fibular head. Arch. Surg., 60; 279-93, Feb 1950 23. Eonar, A, A.: Injuries of the semilunar cartilages in miners: a review of 200 cases, with special reference to the postoperative disability time, Glasgow M. J., 31: 197-205, June 1950 24, Eembrow, C. H., Ahern, A, J. ¥,, Brown, G., Reid, S. S., and Thompson, G, C. V.: Injury to the semilunar cartilage in the knee joint; a re- view of 140 cases, Med, J. Australia, 2: 605-9, Fov 22, 1949 25* Scarfi, G-,t and Gambler, R.: Results of meniscectomy, with special re- ference to arthritis deformans, Arch, ortop., 63: 150, Apr-Jun 1950 26, Scarfi, G., and Gambler, R.: Articular alterations in the knee after meniscectomy, with particular reference to arthritis deformans, Acta chir. patav., 6: 39-47, Jan-Feb 1950 27, Magnusson, R.: Partial synovectomy of the knee joint, Acta orthop. scand., 19: 279-311, 1949 28, Pipkin, G.: Lesions of the suprapatellar plica, J. Bone Surg., 32 A: 363-9. Apr 1950 29* McConville, B, E.: Repair of the collateral ligaments of the knee, Surg. Gyn. Obst., 90: 291-4, Mar 1950 30. Cave, E. F., and Rowe, C. R.: The patella; its importance in derange- ment of the knee, J. Bone Surg., 32 A: 542-53, June 1950 31. Guilleminet, M,; Indications for patellectomy. Rev. med. Moyen Orient, 7: 26-37. Jan-Mar 1950 32. Coode, C. D,: A case of osteochondral fracture of the patella, J. R. Nav, M. Serv., 35: 293-6, Oct 1949 33* Pruvot, Q,: Habitual dislocation of the patella; two operated cases, Rev, orthrop., 36: 51-3, Jan-Mar 1950 209 34. Spray, P. E., and Ghormley, R, K,: Histories and physical findings in 50 cases of chondromalacia of the patella, Proc. Mayo Clin,, 25• 527-6, Aug 30, 1950 35* Coste, E,, Morlaas, J,, and Mauvonisin, F,: Chondromalacia of the pa- tella, Rev. rhonat., 17: 189-92, Apr 1950 36, Prochazka, J,! Is early osteochondritis of the patella really a rare disease?, Acta chir, orthop, traum. Cech., 17: 81-91, Mar 1950 37, Wolf, J,: Larsen-Johansson disease of the patella; seven new case re- cords; its relationship to other forms of osteochondritis; use of male sex hormones as a new form of treatment, Brit. J. Radiol,, 23? 335- 47, June 1950 38, Scuderi, C,, and Schrey, E. L,: Ruptures of the quadriceps tendon. Arch. Surg., 61: 42-54, July 1950 39* Michotte, L, J.j Simultaneous bilateral rupture of the patellar head of the anterior rectus; suture 11 months after the accident, Acta ortho, helg., 16: 81-4, Mar 1950 40, Sarlin, L.: Partial rupture of the tendon of the crural quadriceps, affecting only the anterior rectus femoris. Rev, orthrop., 36: 35- 41, Jan-Mar 1950 41, Capecchi, W,: The Genna constant and its relation to the pathogenesis of arthritis deformans of the knee following static alterations of the lower extremity. Arch, ortop,, 63: 154—9, Apr-Jun 1950 42, Lohe, R,: Plastic surgery of the knee-joint with the aid of the ob- lique plane of the tiblal head. Arch, Elin. Chir, (Langenbeck’s), 264: 488-90, Apr 11, 1950 43, Moffatt, A, A,: Reduction by manipulation of impacted loose bodies in the knee joint. Physiotherapy, Lond,, 135-7, July 1950 210 CHAPTER XV CONDITION’S INVOLVING THE FOOT AND ANKLE By Carl M, Ry lander, Colonel, MC Fitzsimons Army Hospital Denver, Colorado Assisted By James J. Brennan, Lt. Colonel, MC I. Foot A, Disorders involving the toes B, Anatomic deformities 1. Flat foot 2. Others C, Preventive and therapeutic measures D, Footwear E, Methods of stabilization F, The factor of trauma G, Specific conditions II. Ankle A. Traumatic conditions B. Preventive and therapeutic measures C. Specific conditions The 6? articles selected for review in this chapter approach the prob- lem of foot and ankle conditions from anatomic, etiologic, diagnostic, pre- ventive, and therapeutic points of view. Foot Several articles are reviewed which concern various disorders involv- ing the toes. JAROS (l) describes two cases of congenital hallux valgus. There are three types; (a) tri-phalangeal, (b) congenital type associated with supernumerary bone between the first and second metatarsal bones, and (c) familial. Only surgery corrects the deformity, operative procedures being osteotomy of the first phalanx or the first metatarsal or excision of the supernumerary bone. LAKE (2) discusses surgical correction of hallux valgus. Operations mentioned are excision of the bursa and exostosis, Keller's operation, and the author's operation in which the insertion of the adductor and half of the flexor hallucis brevis are transferred to the neck of the metatarsal. CLEVELAND and WINANT (3) give an end result study of the Keller op- eration for hallux valgus in 193 operations, 90 per cent of them in women. 211 The condition is probably due to incorrect foot wear. The authors state that 81 per cent of their cases are bilateral. They advise the use of the tourni- quet at the time of the operation. It is advisable to remove the periosteum with the bone on resection of the proximal half of the proximal phalanx; oth- erwise, the bone may regenerate. One should also be sure to remove all bone chips and the rough edge of the bone. At least half of the phalanx should bo removed. With this operation, a long convalescence is necessary, most of the cases reported remaining in the hospital 15 to 18 days. Since the heal- ing of the wound is rather slow, sutures should not be removed for 12 to days. It is advisable to split or remove the medial side of the shoe to pre- vent pressure, and these shoes should be worn for at least a month. Metatar- sal pads, properly placed, give some relief from pain following surgery. He reports 12 per cent excellent results, 81 per cent good results, and 7 per cent poor results. His rating of excellent means a normal range of motion with complete correction of the valgus; good, a fair range of active motion, that is from 30° dorsiflexion to 10° plantar flexion, with less than 10° of valgus. The complication most frequently encountered is slow wound healing. He reports six infections, with some development of stiffness. HAETWICE (4) discusses the results of various types of operative pro- cedures for hallux valgus. He is of the opinion that the operative proced- ures which shorten the metatarsal or the proximal phalanx produce their main effect through shortening of the extensor hallucis longus tendon. He advo- cates the excision of the proximal phalanx with plication of the capsule to maintain abduction. He reports only 26 cases showing posttraumatic arthri- tic changes in 198 patients operated upon. B INGOLD and COLLIES (5) state that hallux rigidus is a painful condi- tion of the joints of the great toe associated with loss of dorsiflexion of the first phalanx. Early, it is pathologically suggestive of traumatic syn- ovitis, and later it becomes an osteoarthritis. The radiographic picture of increased density and fragmentation is of no significance, as it is seen in normal feet. The cause of hallux rigidus is an abnormal gait developed to protect an injury or an Inflamed joint or to stabilize a hypermobile first metatarsal. This abnormal gait causes an abnormal wear of the shoes, and the author feels that he can diagnose this condition by merely looking at the pa- tient's shoes. JABOS (6) suggests, in cases of hallux varus associated with polysyn- dactylism, the following procedure. A resection of the fibrocartilaginous perhallux should be made with conservation of the skin. Through the same skin incision, a transverse arthrotomy of the first metatarsal phalangeal joint is done, followed by reduction of the first phalanx and fixation of it by two sutures to the second metatarsal bone through a new lateral oval in- cision. Corrective plaster cast is used for four weeks. PITZM (?) explains a technique of operative correction of claw and hammer toes by use of an intramedullary bony graft crossing the joint after position is corrected. This is accomplished by opening the joint, denuding cartilage, and preparing medullary tunnels in both proximal and distal pha- langes into which a tiblal bone graft is levered. OSMOND-CTAHKS (8) states that callosity formation is due to pressure of the bone from within or the shoe from without. Pea cavus causes pressure 212 under the heads of the metatarsals and on the dorsum of the proximal Inter- phalangeal joints. In young, exercises for the intrinsic muscles, stretch- ings, and the use of a metatarsal har and night splints are recommended. T?x- pert fitting of shoes and attention to the callosities are important. In flat feet and metatarsalgia, one must check all causes of pain and not just the flat feet. For hammer toes, he recommends conservative treatment first, and later the operative treatment. He feels that hest results are obtained from tenotomy of the extensor tendons and fusion of the proximal interpha- langeal joint. Callosities require much care, consisting of cutting them down, using faradic foot haths, and wearing roomy shoes and metatarsal pads. The best pad is rubber under chamois, held in place by an elastic band, and this should be properly placed each morning. For congenital contracture of the little toe, he does a Z-plasty of the dkin and divides the extensor ten- don and the capsule. MMDLOWITZ and AB35L (9) report on the measurement of blood flow in the toe in normal patients and in those who have suffered from trench foot and frostbite. There is significantly decreased blood flow in patients who have suffered from frostbite or trench foot. The authors believe this to be due to organic obstruction or constriction of the small arteries of the foot. Four of the articles which deal with anatomic deformities are concerned with flat feet. STAMM (10) states that the two ways in which mechanical de- fects may cause pain of the foot are by excessive pressure on some area or by excessive tension of some tissue. The purpose of fibrous tissue is to prevent excessive movement and not to withstand continuous tension. The lig- amentous tissue, nerves, and muscles should work in unison. Failure of this unison results in tension, and it then causes pain. Excessive tension may alter the shape or posture and result in pressure. The arch serves to sup- port the weight of the body without collapsing. The tibialis posterior and the peroneals act as slings for this arch. The ideal foot should be able to support the weight of the body without tension of the muscles other than for balance, but the normal foot requires tone for the support of the arch. The foot should bo supple. A supple foot usually is not painful, but a rigid foot does give pain. A pes cavus foot has a good arch, but it is often pain- ful because of stiffness. The types of feet that are painful are the stiff foot, the foot with a long arch, and the one with defective muscle tone, A foot that cannot be fully dorsiflexed can get more dorsiflexion with ever- sion, and it then looks flat. This often causes pain. Distinction should be made between a true flat foot, which is of no significance, and one due to eversion. A valgus posture does cause pain. If foot strain has lasted for some time, a state of congestion results, and organization of the exu- date then occurs. Manipulation of these feet may break up this condition and give relief. An exception to this is the spastic flat foot with spasm of the peroneals. According to KITS and LOVELL (ll), there are various types of flat feet, some of which correct themselves, some of which require manipulations and corrective shoes, and some of which require casts and wedgings. Treatment may indicate corrective shoes with the swung-in toe and the heel raised on the medial side, and possibly run forward some. Shoes should be fitted cor- rectly. The author warns of the danger of the use of the fluoroscope in the shoe stores. Corrections are made more rapidly with manipulations. He gives a very definite method of manipulation, and this must be explained very care- 213 folly to the mother, being sure that she understands it. Exercises are also given, and these consist of (a) standing pigeon toed and coming up on the toes several times, (b) standing pigeon toed and inverting the foot, stand- ing on the lateral borders, (c) turning the foot down, in, and then up, while in a sitting position, and (d) in cases of short heel cord, standing pigeon toed a short distance from the wall and leaning forward to the wall with the chest, keeping the body straight. If there is poor cooperation, foot plates may be used. For the more severe cases, easts may be applied with the foot in the corrected position. This works well with a pliable foot, but with a rigid foot the casts will probably have to be wedged. There may be outward rotation of the leg, in which cases, manipulation should be attempted. In the more severe cases, however, a bar between the feet with.the shoes fas- tened to the bar is recommended for correction. In some of the most severe cases, stabilization of the foot may be necessary. HEEZMARK (12) emphasizes the importance of early diagnosis of flat feet in infants. The most important point in diagnosis is the appearance of the foot along with the relationship between foot and leg. Outward rotation or pronation of the foot is apparent at birth. The author recommends treatment with plaster boots applied immediatoly with subsequent weekly changes. Treat- ment is conducted for a month, this being sufficient in most cases. He also recommends a semlreslliant surface for the child*s play pen when standing and walking begins. This prevents passive use of the feet as well as auto- matically exercising them, and the child develops proper walking habits. HOFFMOT-KUMT (13) points oat the otiologic factors in production of flat foot and cavus deformity of the foot. The direction of pall of the tib- ialis anticas is considered a prominent factor* In the correction of flat feet, bony correction by bone resection at Chopart Joints and bone block dis- traction of the posterior portion of the prepared talo-calcaneo Joint are accomplished. These measures produce a laxity of the tibialis anticus at the neck of the talus* In the correction of cavus feet, bony correction is ac- complished, and the tibialis anticus is freed from posterior attachments to pull on the dorso-aedial surface of the first metatarsal* Other articles in this category include a discussion of the occurrence of calcaneo-navicular synosteosis in pes valgus contracture by HERSCHEL and VOH ROMM (l*f). They think that it occurs more often than suspected. Pfitz- ner found it present in 2.9 per cent of 520 foot skeletons. In order to e- liminate errors in diagnosis of this condition, x-rays are obtained in one more plane than usual, so as to show the pathology. This extra view is tak- en at an angle of on the lateral side with the plantar surface of the foot on the film. Slomann suggests three forms of this condition: (a) a com- plete bony bridge, (b) a fibrous cord of syndesmosis, and (c) anphlarthrosis, a kind of stiff Joint. The last two cannot be diagnosed by x-ray, but, if the x-ray shows ossa calcanea secundaria and the patient has clinical find- ings of pes valgus contracture, then the diagnosis of syndesmosis is Justi- fied. HARRIS and BEATH (15) report that there is a specimen of talocalcaneal bridge in the pathological museum of the Royal College of Surgeons of England. HARK (16) discusses rocker foot due to congenital subluxation of the talus. A similar condition may be seen due to improper treatment of club 214 foot* In this, there is an equlnus of the calcaneus with dorslflexlon of the forefoot and some valgus. The talus points downward toward the plantar sur- face of the foot almost parallel with the tihial line* There is a break in the alignment of the mid-tarsal joint so that the navicular faces the dorsal surface of the talus. The cuboid lies above the calcaneus, and the plantar half of the posterior surface is atrophied due to pressure* Previously, as- tragalectomy has been recommended for this as well as removal of the head and neck of the talus. The author does a third type of operation. He length- ens the Achilles tendon and, if necessary, cuts the capsule of the ankle posteriorly. A Steinman pin is then inserted above the calcaneus anterior to the Achilles tendon, and downward traction can be exerted to eliminate the equinus of the calcaneus. Two parallel incisions are then made on the dor- sum of the foot, one over the tarsal sinus lateral to the extensor tendons, and the other medial to the anterior tiblal tendon. The shortened fascia on the dorsum of the foot is then cut, if necessary, on the plantar surface also. The tendons of the anterior tibial and extensor hallucls longus are length- ened. The extensors of the toes are also lengthened in a special manner. If necessary, the flexors are lengthened as well. The dislocation is then reduced. A long leg cast is applied with knee flexed to a right angle, the cast extending to the ankle, and it is then allowed to set. With traction made on the pin, the cast is extended to the mid-foot. When this has set, the forefoot is incorporated into the plaster in plantar flexion. At times, circulatory embarrassment may prevent this last step, and, if so, the foot is brought up as much as possible and changed at four day intervals. Some- times it is necessary to fix the navicular to the talus with Xirachner wires. The thigh portion of the cast is removed in six weeks as well as the pin, and a walking iron is attached. Total immobilization is accomplished for four months. The author reports good results with this procedure. PUX7ERMACHER (17) thinks that the highest incidence of valgus foot is in the second year of life, and it is then 91 per cent. The incidence de- creases from then on. He finds no relation between knock knees or bow legs and flat feet. TREVOR (18) discusses tarso-epiphyseal aclasis, first described in 1926 by Mouchet and Belot. He presents seven cases. They all Involve the knee, ankle, and tarsal bones. If both bones are Involved, the pathology is on the medial side of both bones, or it Involves the lateral side of both. No cases are seen involving the medial side of one bone and the lateral side of the other bone. Initial symptoms are swelling or deformity rather than pain. The bony mass from the overgrowth of the epiphysis causes an enlarge- ment of that area. X-ray changes are confined to the epiphysis. They sug- gest a mass of cartilage tissue with many foci of ossification. The author believes these changes suggest a congenital error in skeletal development as the cause, and he also thinks the limb bud, either pre-axial or post-ax- ial, is affected. The arrangement of the blood vessels in the epiphysis may explain why one side only is Involved. Treatment consists of operative re- moval of the excess bone if it does not jeopardize the stability of the joint. Four deformities of the foot are discussed by HERSCHBL (19)* MEIKR-oTAUFFEE (20) describes a plantar plastic surgery procedure for a pedicle graft. 215 The importance of -preventive and therapeutic measures Is pointed out hy BEOWIT (21) in his discussion of practical foot problems involving the in- fant , child, and adult* The all or none law, as applied to the use of cor- rective appliances and active exercises for the infant, child, and adolescent is stressed* Adequate explanation and instruction to the patient or parents, for a complete understanding of the condition and the value of the types of treatment prescribed, is emphasised as necessary for successful treatment. Those conditions due to muscle imbalance require continued treatment after the condition becomes asymptomatic* The author emphasizes physical medicine procedures applicable to the common foot problems. BOUCHER (22) emphasizes the need for better care of the foot as seen in the number of disorders encountered in children and old people, as well as in examination for the military service. He recommends that the public be educated in the prevention of disabilities and deformities and in the re- alization of the value of, and quality of, well-fitting shoes. LEVIS (23) reports on a syndrome of painful feet in American prisoners of war due to avitaminosis* A complete evaluation of history, incidence, and nutritional background of the patients is presented. This condition is seen to he due to a deficient diet for approximately nine months, during which time several deficiency diseases were prevalent, with this syndrome the most outstanding* The symptoms and signs are due to a neuritis, pri- marily of sensory nerves* The author believes that deficiency of thiamine is the principal, but not the only, factor responsible for the syndrome. JOHES (2*0 discusses treatment of common injuries of the foot. He writes of the stability of the foot and the mechanism causing it. He dis- cusses the anatomy briefly. Injuries of the foot cause pain, and walking then alters the position of the foot to take pressure off the tender areas. This places a strain on other parts and causes pain. Prolonged use and strain cause muscle fatigue and pain. Valgus strain causes pain on the medial side of the foot and a flattening of the longitudinal arch. Treatment outlined is rest, arch supports, and extension of the heel on the medial side. Anter- ior foot strain is described as a strain on the anterior arch due to fatigue of the intrinsic muscles. Rest, use of a metatarsal pad or bar, and a ton- ing up of the muscles of the forefoot are recommended therapeutic measures. March fractures should be treated as other fractures. Crushing injuries are treated by debridement and dressings. For hemorrhage under the nail of the big toe, the use of a dental drill to provide a hole for releasing the pres- sure is suggested. Pads may be of some help in treatment. Metatarsal frac- tures should be treated with a cast for six weeks. When the cast is applied, it should be well-molded so as to form normal arches of the foot; otherwise, the patient may develop a loss of the anterior arch and get a painful foot. In calcaneous fractures, some physicians treat by attempting to reposition the fragments and hold in a cast for eight to twelve weeks. Others give non- weight bearing exercises for the same length of time and, the author thinks, with results. In ankle Injuries, the necessity for distinguishing between sprains and fractures is stressed. In Achilles tendinitis due to wearing of boots, treatment consists of wearing low shoes for the time and then gradually reverting to the boots with the leather softened first. With a bursa over the base of the fifth metatarsal, removal of the pressure of the shoe hastens healing. He gives a group of exercises, both passive and active, for painful feet. 216 McCOMAS (25) discusses disabilities of the foot in the infant and young child. Metatarsus varus, talipes calcaneo-valgus, congenital curled toes, elevated toes, hammer toes, pes planus, pes valgus, and pes cavus are discussed and their manifestations and appropriate treatment are presented. TURNBULL (26) reports a radiological investigation on the weight hear- ing changes in the longitudinal arch of the foot in 100 students. Under the weight of the body, the medial longitudinal arch undergoes an average depres- sion of two millimeters and increases in length four millimeters. One of the feet, usually the right* betrays a secondary change greater than the other. OLIVIER (27) reviews the pathogenesis, distinguishing skin contracture, muscle contracture, paralysis, and osteoarticular lesions of clinical forms of phagedenic clubfoot. The following are the sequelae: pes equinus, pes varus, pes equino-rarus, and pes talus. Treatment is discussed with empha- sis on the prevention of vicious attitude. failure of modern footwear to meet body requirements for psychic and thermal sweating is shown by GAUL and UNDERWOOD (28). They present a study of shoes worn by patients with foot eruptions. They conclude that the leath- er of shoes should be made of material that allows the rapid passage of wat- er vapor so that evaporation from the feet can play its important role in the regulation of foot temperature. BOOTH (29) proposes a prepaid plan which would supply all children with shoes necessary during their growing period. With proper fitting, he feels that the incidence of hallux valgus would be decreased. MITBREIT (30) recommends orthopedic shoes for flat feet. Methods of stabilization in treatment of foot drop are described by MERRITT (31) in a patient with alcoholic neuritis of the peroneal nerve. Ho reports the use of a special device made of a cast, coat hanger, and rubber bands to hold the foot up. BUXTON (32) states that flail foot is due to lower motor neuron les- ions such as poliomyelitis, sciatic nerve lesions, spina bifida, etc. Care- ful initial evaluation is of prime Importance. Paralysis often does not af- fect the foot alone; it may involve the leg, and, therefore, the leg as a whole should be considered and not just the foot. Some patients may be bet- ter off with amputation. Treatment consists of physiotherapy, care of cal- losities, special shoes, and appliances. Operative treatment consists of tendon transplantation, bone and joint operations, and amputation. An at- tempt is made to correct and control the deformities and the instability. PATTERSON et al (33) report an evaluation of 305 stabilizations for various conditions with success in 82 per cent. Residual deformity and pseudarthrosis account for 51 of the 55 failures, and most of the deformities are due to under-correction. later, deformity results from removal of the plaster too soon, failure to align the foot properly, or loss of positioning in the plaster at the time of changing of the plaster. Greater success is attained when three joints are fused. Their calculations indicate ky per cent failure in stabilization on children under eight years of age. Varus and foot drop are the most frequent deformities that remain uncorrected. 217 They find 18 per cent showing pseudarthrosis, most of these occurring at the talonavicular Joint. On the factor of trauma, in foot problems, TYPOTSEY (3*0 reports four cases of dislocation of the tarso-metatarsal Joint. He thinks that it is due to an inherent tendency of this Joint in the oblique direction in relation to the long axis of the foot. HOLSTEIN and JOLDERSMA (35) state that the usual dislocation of the first cuneiform in tarso-metatarsal fracture dislocations is not a problem, but, when there is disruption of the first cuneiform-first metatarsal Joint with outward rotation of the first cuneiform and separation of it from the second, there is difficulty, and it requires an open reduction. Fibers of the anterior tlbial tendon which remain attached to the first metatarsal be— come displaced between the first and second cuneiforms. Traction and mani- pulation do not displace it, and, further, they prevent the reduction of the dislocation. Among the articles pertaining to specific conditions is an article on the treatment of pseudarthrosis of the scaphoid, inner malleolus, and acro- mion by HITHER (36). Arthrosis of the foot is discussed by LELIWRE (37) • An article by PRATT (38) deale with the osteopathic management of an- terior metatarsalgia. POLIVEA (39) reports three cases of Morton’s metatar- salgia treated operatively with the usual findings. Microscopic examination shows fibrosis of the nerves and obliterative changes of the corresponding arteries. OTTOLENGEI et al (40) contribute further data on this subject. MITCEESLL-EEGrG-S (41) describes the treatment of athlete's foot. HOSFORD (42) divides the treatment of ingrowing toenail into the fol- lowing three categories: prophylactic, conservative, and operative. For pro- phylaxis, it is advisable to wear no shoes that compress the toes or the flesh against the nail. The end of the nail should be correctly cut. Con- servative treatment consists of as little walking as possible and the wear- ing of no shoes other than soft slippers. Insertion of something between the nail and the flesh at the edges is sometimes beneficial. Glycerine may be used on this. Strips may be cut from the edge of the nail, even as far hack as the nail bed. In operative treatment, three-eighths of an inch is cut through the thickness of the nail down to the root of the nail. These flaps are dissected up so as to free one-third of the bed. The section of the side down to the base is then cut away, and the base of the nail is cur- etted down to bone, care being taken to get all of it. Finally, the skin flap is replaced but not sutured. BOBEOFF (43) presents a case report of plantar warts treated with a keratolytic agent consisting of 40 per cent salicylic acid in plaster, A small piece of plaster is cut the size of the wart and applied to it, held in position by other plaster. He finds that 20 per cent of cases so treated develop abscesses underneath the wart, the abscesses becoming apparent about two weeks after beginning treatment. It is felt that chemical treatment should be tried before any irradiation begins. HARO (44) discusses asymptomatic occurrence of ringworm of the feet in Finland. 218 HUESSLE (45) reports a case of Madura foot, observed over a period of 15 years, and finally resulting in amputation. He feels that amputation is the treatment of choice. Additional information on Madura foot is presented hy MEYER (46). CAMPBELL et al (4?) report their follow-up study of 149 cases of throm- boangiitis obliterans, about 45 per cent requiring amputation. This compares with previous reports. Superficial migratory thrombophlebitis is shown to precede clinical occlusive arterial lesions. If sympathectomy is to be done, it should be done early in the disease. When the patient remains under rigid supervision of interested physicians, major amputations are reduced to a min- imum. The large number of patients who are still living have not ceased the use of tobacco. Psychosomatic factors appear to aggravate the condition. REDISCH and BRAM)MAH (48) evaluate five vasodilator drugs in treatment of chronic trench foot. The drugs are aminophylline, papaverine, etaiaon, priscoline, and reniacol tartrate. Hone of the first four mentioned are ef- fective. Reniacol tartrate produces some improvement in 44 per cent with little side effect. Careful clinical examination is the only basis for the authors' evaluation. Ankle Various articles appear on traumatic conditions of the ankle. STUCKE (49) considers the elastic behavior of the tendon of Achilles in experimental rupture. SOMERVILLE-LARGE (50), in discussing strains of the ankle joint, con- tends that some degree of tilting of the talus on inversion of the plantar flexed foot is normal. Due to the anatomy of the calcaneo-fibular and talo-fibular ligaments, the former is tight on dorsiflexlon, and the lat- ter is tight on plantar flexion. HUDSON (51) calls a tlbio-fibular diastasis a ligamentous fracture. Examination of the patient after about an hour shows that there is antero-lateral swelling of the ankle, limitation of flexion and extension, no inversion, a tendency to valgus position, a spasm of the per- oneal muscles, and an unstable ankle. X-rays, as routinely taken, are nega- tive, When taken with forced inversion, they show that the talus can bo rocked out. All these findings and symptoms are aggravated after a few hours. The author's treatment consists of a subcutaneous tenotomy of the peroneals which, he states, gives immediate relief. He then applies a long log cast for six weeks and then a plaster boot for four more weeks. Patients walk af- ter four weeks in the cast. VAN de VDORDE et al (52) outline the treatment of the sequels of ankle injuries, and SAHA (53) discusses various injuries of the ankle and their management. (Ed: The latter is a particularly well-presented, detailed ar- ticle.) The necessity of obtaining proper alignment of the ankle mortise and the satisfactory reduction of supra-malleolar areas are emphasized. The importance of adequate x-rays in cases of injury with pain, swelling, and tenderness in the ankle area is re-omphasized. HISSL (54) emphasizes the necessity, in acute sprains of the ankle, of determining whether there is actually a sprain. In case the distance between the talus and the internal malleolus is equal to or larger than the width of 219 the horizontal joint, tears of the ligament can he diagnosed from a single A-? view. CHESHBY (55) states that, in order to get a proper x-ray view of the ankle, one should have the patient lie on the affected side with the sound limh behind the affected one. The ankle is placed on a low box on the table with the foot projecting distal to the box. This prevents any inver- sion of the foot, which he feels is the cause of some of the failures. The knee is not supported. The tube is directed one-half inch proximal to the lower end of the medial malleolus. RACKDW (56) suggests four x-ray views of an injured foot. Standard antero-*posterior and lateral views are taken. The oblique view is obtained by having the plantar surface of the foot on the film and then tilting the leg medially The fourth view is taken with the plantar surface of the foot on the film and the ankle in dorsiflexion, the tube being posterior and directed downward toward the calcaneus. Minimal fractures, erroneously called sprains and treated as such, often result in prolonged disability. The author discusses various fractures of the bones of the foot and precau- tions to be taken in order to avoid mistaken diagnoses. Preventive and therapeutic measures are presented in two articles. His study of the various methods of strapping and supporting ankles in athletes is reported by McPHEE (57)* He finds figure of eight bandages of adhesive to be the most effective, but they cause irritation of the tibialis anticus tendon. A modified figure of eight with heel support, using muslin, is good. A shoe padded over the malleoli and under the tongue, as suggested by Scott, is also good. A modified Gibney bandage is useful. The author checks these results by x-ray. SWyNGHEDAUS (58) reports two cases of tibio-peroneal diastasis, both having considerable difficulty. He states that operation, in both cases, consisted of dividing the fibula two inches above the tip, cleaning out the tlbio-flbular gutter and then replacing it, fixing it to the tibia with a cross bolt. A rapid cure in both cases is reported. Numerous specific conditions involving the ankle are Illustrated by representative case reports. BISOTTI (59) reviews the few cases of anterior luxation of the head of the fibula which have appeared in the literature and presents a case of his own. His case is unusual in that detailed account of the movements responsible for this injury can be described. He reports it to have been produced by internal torsion of the thigh in which the right foot was unable to follow. His treatment consists of reduction by traction and direct manual pressure under local novocain anesthesia. Complete relief of pain results from reduction. Immobilization is used for 20 days postre- duction. CARTER et al (60) report nine cases of an entity called the anterior tibial syndrome. These patients give histories of strenuous use of the leg muscles just before or at the time of the onset of symptoms, followed by swelling of the anterior tibial compartment, classical signs of inflamination, and, later, foot drop. Two cases followed transfusions into the veins of the leg. The other muscles of the leg remain normal. The affected muscles are hard and indurated, responding neither to galvanism nor faradlsm. Five cases show silent electromyograms, indicating fibrosis or necrosis of the muscle. Arteriography shows no evidence of thrombosis of a large artery. 220 Biopsy shove microscopic and macroscopic massive ischemia, necrosis of mus- cles with replacement fibrosis* The treatment is complete rest, elevation and limb splintage, and early decompression of the anterior compartment as paralysis occurs. Two cases of leprosy involving the talus are reported by ERICKSON and MAYORAL (6l), both cases showing osteolytic lesions* Since this has not pre- viously been reported in the literature, routine x-rays on 441 patients with leprosy are used for clarification. Five of these patients show previously unrecognized lesions of the talus, occurring in the neck of the talus, usu- ally at the Junction of the neck and the body at the site of the best blood supply, and only in patients with lepromatus or mixed leprosy. Healing of the lesion is accomplished fairly rapidly if weight bearing is prevented dur- ing the healing phase. SIMPSON (62) reports a case of osteochondritis dissecans of the talus, Including operative findings and postoperative results. Satisfactory out- come is reported. He reviews the literature and finds few other cases of this type reported. ROCA and ANTELO (63) present a case of complete dislocation of the tal- us antero-laterally with inversion of 90°, satisfactorily reduced with a good functioning foot. WOLHf et al (64) feel that persistent or recurrent pain and swelling over the fibular aspect of the ankle Joint are, not infrequently, residuals of an old inversion sprain. The patient may describe it as a weak or trick ankle. The authors feel that this is not usually due to a tearing of the ligament. There is some tearing of tissue with a sprain, accompanied by hem- orrhage. This usually subsides, but occasionally it does not. It gives rise to a traumatic synovitis with synovial thickening and exudation. Part of this tissue may remain between the malleolus and the talus where it may become hyalinlzed. Pinching of this tissue frequently causes pain and swell- ing. This is called a menlscoid lesion, and, with its removal, the patients get complete relief. They report success in nine cases. Non-specific inflammatory lesions of tendons are divided into three groups by LAPIDUS and SEIDMSTEIN (65). The groups they name are peritendin- itis, stenosing tenosynovitis, and chronic tenosynovitis with effusion. In peritendinitis crepitans, there is a deposition of fibrin in the peritendin- ous and perimuscular areolar tissue. It is often of an occupational nature. Crepitus can be felt, and it is worse early in the morning. Rest and physio- therapy invariably relieve the'condition, Stenosing tenosynovitis occurs only in tendons with a synovial sheath. This is most often seen at the ra- dial styloid process, involving the tendons of the abductor pollicls longus and extensor pollicls brevis. It may also occur as a trigger finger on the palmar aspect of the metacarpals. Some early cases get relief with rest, but most of them require surgery. Most commonly, a chronic effusion in the synovial sheath is due to tuberculosis. The sheath is distended with fluid and contains typical rice bodies. Tuberculosis and suppurative forms are not included in this third class, however. A chronic tenosynovitis with ef- fusion most often involves the Achilles tendon. The symptoms may be present intermittently, and the condition may go unrecognized even for years. At op- eration, it shows an increase in synovial fluid with thickening of the sheath. 221 Luster of the tendon is gone. Some have a purplish discoloration. The auth- or excises most of the sheath, and the patient obtains relief following this procedure. One case of rupture of the tendon of the tibialis anticus muscle is described by STRASSBURGER (66). This is apparently rare, as he found only six other cases reported in the literature. GIEDWOOD (6?) discusses gravitational leg syndrome. He states that ex- cision of an ulcer, including the surrounding scar tissue and the deep fascia, and exposure of the underlying muscles, followed by skin grafting, is the treatment of choice. In 20 divisions of the superficial femoral vein, 13 show no change or an aggravation. Seven are much improved. 222 BIBLIOGRAPHY 1. Jaros, M,: Congenital hallux valgus, Acta chir. orthop. traum. Cech., 17: 75-81, Mar 1950 2. Lake, K.C*s Hallux valgus, Med. Press, Lend., 223: 568-73* June 14, 1950 3# Cleveland, M., and Winant, E.M,: An end-result study of the Keller operation, J. Bone Surg,, 32 A: 163-75. Jan 1950 4. Hartwich, A,: Surgical technic for hallux valgus, Wien, Klin, Vschr., 62: 249-50, Apr 7, 1950 5. Bingo Id, A. C., and Collins, D, H.: Hallux rigldus, J, Bone Surg., 32 B: 214-22, May 1950 6. Jaros, M.j Hallux varus and its therapy, Acta chir. orthop. traum. cech., 17: 151-61, 1950 7. Pitzen, P.: Treatment of claw and hammer toes hy means of an osseous holt, Zschr. Orthop., 79: 383-5. 1950 8. Osmond-Clarke, H.s Contracted toes and callosities, Med. Press, lend., 223: 561-5. June 14, 1950 9. Mendlowltz, M,, and Abel, H. A.: Quantitative blood flow measured cal- orimetrically in the human toe in normal subjects and in patients with residual of trench foot and frostbite. Am. Heart J., 39: 92-B, Jan 1950 10. Stamm, T, T.: The treatment of flat foot, Med. Press, Lond., 223: 559-61, June 7. 1950 11. Fite, J. H., and Lovell, V. ¥,• Treatment of flat feet in children, J. M. Ass. Georgia, 39: Aug 1950 12. Horzmark, M, H.j Plat feet in infants, Med, Ann. District of Columbia, 19: 315-6, June 1950 13. Hoffmann-Euhnt, H,! Anterior tibial muscle in flatfoot and talipes cavus, Zschr. Orthop., 79: 519-21, 1950 14. Eerschel, H., and Yon Ronnen, J, R.: The occurrence of calcaneonavi- cular synosteosis in pes valgus contractus, J. Bone Surg., 32 A: 280- 2, Apr 1950 15. Harris, R. I., and Beath, T.: John Hunter’s specimen of talocalcaneal bridge, J, Bone Surg., 32 B: 203, May 1950 16. Hark, P. W.i Rocker-foot due to congenital subluxation of the talus, J. Bone Surg., 32 A; 344-52, Apr 1950 223 17. Pulvermacher, I.: Orthopedic problems in Israel; the problem of the ▼algos foot, Hebrew M, J,, 23i 155-60* 1950 18. Trevor, D.: Tarso-epiphyseal aclasis; a congenital error or epiphyseal development, J. Bone Surg., 32 B: 2o4-13, May 1950 19. Herschel, H.: Pour deformities of the foot, Med, mbl., 3 2 18*t-9» May 1950 20. Meier-Stauffer, G.: Pedicle graft in plantar plastic surgery, Wien, med Wschr., 100: -Apr 22, 1950 21. Brown, J. E,: Practical foot problems. Arch. Phys. M., 31s 101-6, Peb 1950 22. Boucher, C. A.: The care of the feet, Med. Press, Lond., 223: 57^7, June l*f, 1950 23. Lewis, R. B.: Painful feet in American prisoners of war, U. S. Armed Forces M. J., 1; Feb 1950 Jones, G. B.: Common injuries of the foot, Med. Press, Lend., 223: 582-5, June 1950 25. McComas, E.: Disabilities of the foot in the infant and young child, Med. J, Australia, 2: 620, Hov 22, 19^9 26. Turnbull, G. M,: A radiological investigation of changes in the human foot, Med. J. Australia, 2: Sept 19^9 27. Olivier, G,: Clinical forms of phagedenic clubfoot, Afrioue fr. chir., —S 25-8, Jan-Mar 1950 28. Gaul, L. E., and Underwood, G. B.; Failure of modern footwear to meet body requirements for psychic and thermal wweating, Arch. Derm. Syph., Chic., 62; July 1950 29. Booth, W. G.: The foot of the civilized man, Med, Off., Bond,, 82; 209, Nov 12, 19^9 30. Mitbreit, I. M,; Orthopedic shoes in flat foot, Tr. Tsentr. naucho- noissledov. Inst, protez., Moskva, 3* 126-31, 19^9 31. Merritt, L, E.: A new approach to the treatment of foot-drop, Canad. M. Ass. J., 63; 77, July 1950 32. Buxton, S, J, D,: Treatment of flail foot, Med. Press, Lond., 223• 565-8, June 1950 33* Patterson, H, L,, Jr., Parrish, P. P., and Hathaway, E, H.; Stabiliz- ing operations on the foot; a study of the indications, techniques used, and end results, J. Bone Surg., 32 A: 1-26, Jan 1950 Typovsky, K.; Dislocation of Lisfranc's joint, Lek. llsty, 5i 3H-5t June 1, 1950 224 35• Holstein, A., and Joldersma, H. D.; Dislocation of first cuneiform in tarsometatarsal fracture-dislocation, J. Hone Surg., 32 A: 419-21, Apr 1950 36. Rather, H,: Treatment of pseudarthrosis of the scaphoid, inner mal- leolus, and acromion, Zschr. Orthop., 79: 485-99# 1950 37. Lelievre, J,! Arthrosis of the foot, Medecin fr., 10: 162-4, June 10, 1950 38. Pratt, tf. A.: The osteopathic management of anterior metatarsalgia, J, Am, Osteopath, Ass,, 49: 142-4, Hot 1949 39» Polivka, D,; Morton’s neuralgia, Acta Chir. Orthop. Traum. Cech,, 17: 119-22, 1950 40. Ottolenghi, C. E., Petracchi, L. J,, and Schajowicz, P.: Morton’s Metatarsalgia, Rev, As. med. argent., 63: Nov 15-30, 1949 41. Mitchesll-Heggs, B.: Treatment of athlete's foot, Med, deporte, 15: 3340-50, May 1950 42. Hosford, J.: Ingrowing toe nail, Practitioner, Lond,, 164: 278-80, Mar 1950 43. Bohroff, A,: Abscess complicating plantar wart. Northwest M,, 49: 352. May 1950 44. Haro, S.: On the asymptomatic occurrence of ringworm of the feet in Finland, Ann, med. exp. hiol. fenn, 27: 73-7* 1949 45. Nuessle, R. P,: Madura foot or myctoma pedis, J. lancet, 70; 295-7# Aug 1950 46. Meyer, P, S.: Madura foot, Zschr. Haut & Oeschlker., 8: xl. May 15# 1950 47. Campbell, K, N,, Harris, B, M,, and Collier, P. A.! A follow-np study of patients with thrombo-angiitis obliterans (Buerger’s disease). Surgery, 26: 1003-13# Dec 1949 48. Redisch, W,, and Brandman, 0,; The use of vasodilator drugs in chronic trench foot, Angiology, Is 312-6, Aug 1950 49. Stucke, K.: Elastic behaviour of the Achilles tendon in experimental rupture, Arch. Klin. Chir, (Langenbeck*s), 264: 589-90# Apr 11, 1950 50. Somerville-Large, C.s Strains of the ankle joint, Irish J. M. Sc,, 6; 225-8, May 1950 51. Hudson, 0, C.; Ankle sprain or ligamentous fracture of the ankle, Med, Times, N. Y., 78: 291# July 1950 52. Van de Voorde, C., De Wulf, A., and Vereecken, E.: The treatment of 225 the sequels of ankle injuries, Acta orthop. belg., 16: 117-224, Apr 1950 53. Saha, A. K.: Injuries at the ankle and their management, Ind. J. Surg., 11: 139-54, Sept 1949 54, Nissl, R.: Roentgenography of injuries of ankle joint, Portsch. Ront- genstrahl., ?2: ?22-7, Apr 1950 55* Chesney, M. 0.; Technique of a lateral view of the ankle joint. Radi- ography, Lond., 16: 28, Peb 1950 56, Rackow, A. M,: The value of radiography in the diagnosis of injuries of the foot, Med. Press, Lond., 223: 577-82, June 14, 1950 57, McPhee, H, R.: Ankle protection; a study of methods used in athletics, J, lancet, 69: 426-8, Dec 1949 58, Swynghedaus, Salemhier: Surgical treatment of tihioperoneal diastas- is; two cases, Lille chir., $: 144-7, May-June 1950 59* Bisotti, P. L.: Anterior isolated .luxation of the head of the fibula, Riforma med., 64: 80-3, Jan 21, 1950 60. Carter, A, B., Richards, R. L,, and Zachary, R. B,: The anterior tib- ia! syndrome, Lancet, Lond., 2: 928-34, Nov 19, 1949 61. Erickson, P. T., and Mayoral, A,; An unusual lesion of the talus oc- curring in leprosy. Radiology, 357-64, Mar 1950 62. Simpson, T, R,: A case of osteochondritis dissecans of the ankle, Brit. J. Surg., 37: 359, Jan 1950 63. Roca, C. A., and Antelo, J. H.: Total dislocation of the astragalus, Prensa med. argent., 37: 1012-6, May 12, 1950 64. Wolin, I., Classman, E., Sideman, S., and Levinthal, D. F.: Internal derangement of the talofibular component of the ankle, Surg. Gyn. Obst., 91: 193-200, Aug 1950 65* Lapidus, P. W,t and Seidenstein, H,: Chronic non-specific tenosyno- vitis with effusion about the ankle; report of three cases, J. Bone Surg., 32 A: 175-9, Jan 1950 66. Strassburger, P,: Rupture of the tendon of the tibialis anticus, J. M, Soc. N, Jersey, 47: 281-2, June 1950 67« Girdwood, W,; Gravitational leg syndromes, S. Afr. J. Clin. Sc., 1: 11W39, June 1950 226 CHAPTER XVI CONDITIONS INVOLVING THE SHOUIDER AND NECK By Victor B, Vare, Lt. Colonel, MC Valley Forge Army Hospital Phoenlxville, Pennsylvania Assisted By Hovell E, Wiggins, Commander, MC, USN Philadelphia Naval Hospital I, Shoulder Joint A. Operative technique* B. Arthrography C. Painful shoulder conditions 1. General 2. Bursiti* 3. Capsulitis D. Dislocation of the shoulder 1. Surgical treatment 2* Fracture dislocations 3* Unusual cases E. Miscellaneous conditions II• Shoulder girdle A, Acromio-clavicolar area B, Scapular region C, Muscular involvement III. Neck A. General discussion B. Cervical spine C. Muscles D. Nerves B. Cervical rih There are 76 articles reviewed in this category. Shoulder Joint Operative techniques are suggested hy two authors. A transacroaial in- cision for exposure of the shoulder Joint is described hy 1KATCHER (1). It is a simple operative procedure for safe exposure of the superior aspect of the gleno-hamoral Joint which assures adequate exposure for repair of tom tendons. HUARD and MONTAGNE (2) describe the anterior approach to the whole hu- merug from the shoulder Joint down, crediting it to 0* Mason (British Jour- nal of Surgery, 1929)* Arthrography of the shoulder Joint is discussed hy KESSEL (3)* vko uses 8 to 10 cc* of 35 per cent pyelosil in his technique* 25 satisfactory exam- inations are the basis for his disagreeing with Nevasler’s view that adhe- sions exist between the synovial membrane and the head of the humerus* He also disagrees with Lippman’s premise that the underlying lesion in a "froz- en shoulder" is bicipital tenosynovitis* The author further conjectures that the gleno-humeral Joint may be a "blameless structure, much aligned" and the acromlo-clavlcular Joint may be the origin of many so-called supraspinatus disorders* WARRICK (*0 wisely champions true lateral projections of the gleno- humeral Joint* He describes a supero-inferlor projection and its counterpart, the infero-superior projection. Numerous articles appear in the literature pertaining to various as- pects of painful shoulder conditions* A summary of treatment of patients with painful shoulders is presented by HARMON et al (5)» These are cases selected from a larger group of some cases seen over a four-year period. The sub-deltoid bursa is felt not to be a factor in the painful shoulder syn- drome* The author states that 292 cases, or por cent of the total number, are frozen shoulders; 130 are due to calcifications in the rotator cuff ten- dons* Bicipital tendinitis, suprasplnatus tendinitis, or ruptured supraspln- atus account for the remaining cases presented* Many types of treatment are used and evaluated* The following conclusions are drawnr (a) surgical exci- sion of calcifications about the shoulder Joint affords the most prompt and effective relief of symptoms, said there is no evidence that roentgen therapy Itself causes a disappearance of calcified deposits, (b) manipulation of stiffened or frozen shoulders under general anesthesia and a regime of post- manipulative exercises result in a normal range of motion* These measures give a high percentage of cures with little or no subsequent disability; how- ever, the recovery period may take several weeks, (c) lacerations or tears of the suprasplnatus tendons should be repaired surgically, and (d) roentgen therapy may be used to relieve acute shoulder pain, but there remains a high percentage of patients that are unrelieved by this method* It is advised that rest, hot or cold applications, and ethyl chloride spray be used in preference to x-ray* Local procaine injections are inferior to other meth- ods, and diathermy frequently accentuates the patient’s symptoms* The results of treatment of subacromial bursitis in 3**0 cases is of- fered by CALDWELL and UNKAUP (6), These authors evaluate the results of var- ious therapeutic measures including one per cent procaine infiltration, roentgen therapy, and surgical excision (all with physical therapy as an ad- juvant) in these followed-by-mail cases* They conclude that satisfactory re- lief of pain and restoration of function may be obtained by conservative mea- sures 4in 70 to 85 per cent of cases* Roentgen therapy is effective in 85 per cent of cases, and physical therapy alone is adeouate for many mild or subacute chronic cases* Recurrent attacks can be anticipated in 22 per cent of acute or subacute cases and in 33 per cent of cases with chronic symptoms* Operative attack on the old, severe, frozen shoulder type proves most effec- tive* 228 A total of cases of peritendinitis calcarea of the shoulder are analyzed by GALLUCCIO and HERSCHER (?)• In these cases, slightly more than half being in females, no definite etiological factor is demonstrable. Typ- ically, an acute case presents severe pain about the shoulder with radiation to both neck and arm. Limitation of motion, particularly abduction, and ex- quisite point tenderness over the area of the greater tuberosity of the hu- merus are classical findings. Roentgenographically, the majority of cases reveal calcific deposits near the supralateral aspect of the humeral head, and x-rays should bo taken with the hand in both extreme pronation and supin- ation to avoid missing calcific areas. The absence or presence of calcifi- cation and the degree of calcification, if present, are not criteria as to the acuteness or severity of the attack, but cases without demonstrable cal- cification do not ordinarily respond to therapy as dramatically as do those with calcification. The authors believe x-ray therapy to be the treatment of choice, especially in the acute and subacute stages of the disease, al- though the precise reason for relief of pain following exposure to x-rays is not clear. The dosage advised is 300 roentgens (measured in air) using a 10 x 15 cone at 50 centimeters distance. This is administered to the anter- ior portal every other day. The authors report their results with the above treatment, administered to 219 acute cases. Complete relief is obtained In more than 80 per cent, 50 per cent improvement of pain and range of motion in 15 per cent, and no relief in 5 per cent. 70 per cent of 111 subacute cases show relief, while less than bO per cent of chronic stage cases ex- perience any degree of improvement. Roentgen therapy for bursitis of the shoulder is described by RUBIN (8) and ROBINSON (9) with details of diagnosis, amount, and technique of ra- diotherapy. For x-ray treatment purposes, the latter classifies the cases as acute or chronic although there is no definite line of demarcation, and he excludes such conditions as rupture of the supraspinatus tendon and acute traumatic bursitis. All patients suspected of having bursitis should have roentgenograms taken with the humerus in internal and external rotation. Although a gross calcific deposit lateral to the greater tuberosity is one of the most positive roentgenographlc findings supporting the diagnosis of bursitis, neither its size nor presence or absence is related to the sever- ity of the symptoms. In suspected cases, one should also consider arthritis, fracture of the humerus, neoplasm, inflammatory changes, herpes zoster, cal- cinosis universalis, angina pectoris, neuralgia, brachial plexus syndrome, cervical spondylitis, tuberculosis, and syphilis. The author*s treatment schedules and data are presented. He records a satisfactory response in 83 per cent of 6l cases treated with deep roentgen therapy. IANDA BACALLA0 and DIEGO CABALLERO (10) discuss iontophoresis in the treatment of acute subdeltoid bursitis. On the subject of capsulitis, there is a scholarly treatise by FISCHER and LEATHERMAN (11) dealing with acute, subacute, and chronic tendinitis of the rausculo-tendinous cuff of the shoulder in a concise form. BUHMAW (12) reports a “proven at surgery1* case of an enlarged coracoa- cromial ligament responsible for compression of the supraspinatus tendon and simulating supraspinatus tendon tear syndrome. Microscopic examination, how- ever, shows extensive degeneration of the tendinous and capsular tissue. 229 SEZE et al (13) present two cases of bicipital tendinitis which give all of the findings of a subdeltoid bursitis with the exception of exquisite point tenderness over the bicipital groove. In each case, they obtain ex- cellent results by modifying Codman1s procedure slightly. The authors* pro- cedure exposes the bicipital tendon where, in each case, they find a chronic Inflammatory synovitis surrounding the normal bicipital tendon. One revealed cartilaginous metaplasia of the synovia. The intertuberus ligament is in- cised and its edges sutured to the tendon with two strong linear sutures. The tendon is then severed above these sutures, and the proximal fragment is allowed to retract. They report that both patients were able to return to full work with strength commensurate with their Jobs, one a laborer and the other a secretary. Ranges of motion are reported as only slightly limited with normal to slightly diminished strength of the biceps. JAMPOL (1*0 gives exercise treatment for the frozen shoulder in an ab- stract of a master’s thesis from Stanford University Division of Physical Therapy entitled "The Exercise Program for the Shoulder with Limited Motion." It is and complete in its presentation. Humero-scapular periarthritis is described rather completely and thor- oughly by STENGEE and GUSE (15) with special emphasis on etiology, diagnosis, pathology, treatment, and prophylaxis. Treatment is chiefly by various kinds of heat, light, and exercises, S55IE (16), on the same topic, gives a com- prehensive treatise considering the diffuse and localized forms of the condi- tion and all known types of preventive and curative measures, and REYMOND (1?) treats the subject from anatomic, pathologic, and clinical points of view. The latter also describes a technique of novocain infiltration in treatment. SEZE et al (IS) present a philosophic discussion of supraspinatus ten- don calcification and state that the application of ice exerts a favorable effect in the disappearance of such calcification. They explain that the cold contracts the arterioles, causing poor elimination of the by-products of cellular metabolism which, in turn, produces a certain degree of acidity. It is known that an acid pH favors dissolution of calcium deposits. GOUHARIS (19) gives a brief resume of the technique of radiotherapy of scapulo-humeral periarthritis* ESROliD (20) describes the technique of tetraethylammonium therapy of pain in the shoulder. This substance paralyzes the sympathetic synapses, thus giving a temporary chemical sympathectomy and parasympathectomy. DUEOUR and BOISSY (21) report x-ray treatment of four shoulders and one hip with calcifying lesions, resulting in relief of symptoms. Dislocation of the shoulder is a common topic for study «nd discussion. T0W1TLEY (22) gives an excellent presentation defending Ban h ar t 's premise of anterior capsular lengthening or defect being responsible for recurrent anterior dislocations of the shoulder. JEHS (23) advocates the Magnuson procedure for reducing recurrent dis- locations of the shoulder. He describes the method and evaluates the favor- able results of 11 cases. PALUMBO and QUIRDT (2*0 discuss the anatomic fea- 230 tures, pathologic features, and various operative procedures relative to re- current dislocations of the shoulder* They offer 13 cases in which very slightly modified Magnuson-Stuck procedures were performed and the patients followed for six months to three years* Conceding the brevity of the fol- low-up period, they report no recurrences to date* The end-results of 12 cases of old (existing longer than a few weeks) dislocations of the shoulder are evaluated by RUCKER and CAVALCANTI (25) vho conclude that ankylosing methods of therapy a3*o preferable since open oper- ation is necessary for reduction although the latter is difficult to main- tain* They also state, however, that under special circumstances, princi- pally in old people, the resection of the humeral head can be done because of its simple techniques. CASTILIO (26) describes in detail the technique of treatment of recur- rent dislocation of the shoulder by the Gallle-Lemesurler technique and re- lates his experience in 11 cases treated by this fascial sling operation* COVILLE (2?) describes treatment of recurrent dislocations of the shoulder by suspension of the humerus to the acromion using a ligament of silk* LE- PINB and LANGEVIN (28) report the results of 39 recurrent dislocations of the shoulder operated upon by one of the following three methods: a bony buttress, Nicola’s method, or method of Puttl-Platt* SCEIER et al (29) pre- sent a two paragraph discussion of the operation of Nicola and a patient treated by this method* A series of unusual fracture-subluxatlons of the shoulder Joint is re- ported by THOMPSON and WINANT (30). Their study is based on six case his- tories collected from January to July representing an Incidence of 20 per cent of fractures occurring about the shoulder Joint* They feel that these fracture-subluxations of the shoulder Joint should be classified as an entity in themselves* Following experimental work in which they dis- prove Pairbank’s theory of muscle relaxation about the shoulder Joint as an etiological factor in this condition, the authors conclude that fracture- subluxatlons of the shoulder Joint constitute a primary stage of a fracture- dislocation of the humeral head with partial tearing of the capsule* They feel that early surgery is not indicated, in that the condition tends to im- prove spontaneously with proper treatment such as sling support and early horizontal gravel exercises* Hanging cast therapy has no place in the treat- ment of this entity* MICEAELIS (31) describes a case of internal rotation type dislocation of the shoulder discussing the difficulty in demonstrating it by radiologi- cal techniques (unless a vertical view is obtained)* The clinical picture of locking of the arm in adduction in inward rotation is the basis of diag- nosis* HOWELL (32) discusses and pictorally presents patients who, in the quiescent phase of rheumatoid arthritis, develop limited shoulder function, on occasion quite severely, due to supero-anterior subluxation of the head of the humerus, the latter articulating with the acromion and clavicle and creating a false Joint* Treatment attempted is weekly novocain Into the “new” Joint and manipulations. Keen evaluation of this therapy is not in- cluded, however* 231 Among the miscellaneous conditions involving the shoulder Joint is a description of rupture of the musculo-tendlnous cuff of the shoulder by ASE- SRMAN (33)* He enumerates the diagnostic signs as (a) absence of restriction of passive motion, (b) presence of atrophy of muscle, Involved in two weeks, (c) wide separation of tuberosity fracture fragment. Dependable signs, though not diagnostic, are absence of calcium deposits, palpable rupture, and soft tissue crepitus* The author advocates the use of a sling or swath for two weeks before deciding to do surgical repair. Surgical intervention should be done if symptoms and disability are severe after a period of two weeks* He quotes the study of McLaughlin on 100 tears of the cuff repaired surgical- ly. LADURON (34) reports a case of extensive destruction of the humeral head replaced by a metallic prosthesis. The prosthesis comprises about one- third of the length of the bone, and at its lower end there is a long, cup- shaped recess containing the humeral shaft. The destruction is reported to be due to a shotgun wound, and the many lead pellets in the region seem to have no adverse effect upon the stainless steel prosthesis* MILLER and HILKEFITCH (35) review the literature on osteochondritis dissecans of the shoulder Joint and report one case treated by excision* The pathology, gross and microscopic, is presented. Shoulder Girdle Articles concerning the acromio-clavicular area include a description hy TARRAHT (36) of a method of procuring an axial view of the clavicle* HATEANSOR and SI/)BODKIR (37) describe acromio-clavicular changes in three cases of hyperparathyroidism and conjecture the possibility of its be- ing a presumptive sign. ALEXANDER (38) offers a "shoulder forward" lateral x-ray technique to facilitate radiographic demonstration of dislocation of the acromlo-clavic- ular Joint* TYPOVSKY (39) reports two cases of clavicle extirpation for tumor and carcinoma metastasis. There is no post-operative shock, the period of in- validity is short, and the functional results are excellent* Two cases of luxation of the sterno-clavicular Joint are reported by STAPELMOHR (40) for which he uses a method of surgical treatment which he described in the sane Journal in 1932* REYMOHD (41) writes an addendum to a previous publication on the oc- casion of having read the technique described by Drist employing a plaster cast with an elastic webbing strip in treating acromio-clavicular luxations* DOHLER (42) describes the treatment of acromio-clavicular dislocations with a temporary pin transfixation. The syndrome of snapping of the scapula is reviewed by MILCH (43) who presents the several etiological factors which may cause It. Four cases are presented illustrating the different causative factors* One is a case with a typical bulbous thickening at the upper angle of the scapula which is felt 232 to represent a tubercle of Luschka. The second is found to be due to a typ- ical, benign osteochondroma in a 13 year old child. The third case. In a three year old female, is found to be due to a congenital malformation of the sixth and seventh cervical spinous processes with a bony projection from this area toward the angle of the scapula. The last case is found to be due to a simple anterior angulation of the superior angle of the scapula which crepitated over the posterior aspects of the ribs on motion. The author sug- gests that the last case presented represents the most usual finding in the ordinary case of snapping of the scapula. The remaining cases may vary as to etiology and character. Trauma may seem to play some part in the preci- pitation of the patient’s symptoms. The crepitus originates as a result of the contact between the chest wall and the scapula. 'Elevation of the sca- pula from the chest wall leads to immediate cessation of the sound and is an excellent diagnostic point. In all cases, the localization of the noise determines the site of resection. Simple removal of the portion of the sca- pula involved, as in the cases presented, will result in prompt and perman- ent cure. The scapular region is the site of injury in a case report by LARGHERO YBARZ (4*0. He reports the penetration of the axillo-scapular pyramid, an- terior to posterior, by a wooden pole, the firm fixation of the pole in the tissues necessitating surgical removal. X-rays reveal that the thorax had not been entered and that there were no rib fractures. Clinical examination reveals that the neurovascular bundle of the axilla had not been damaged. The author reports surgical removal of the pole with wide debridement. Surg- ery reveals the destruction of the mid-portion of the scapula by the trau- matic agent causing extensive damage to the scapular muscles. A satisfactory postoperative course is reported. Muscular involvement in shoulder girdle conditions is shown by HAYES (4$) in his study of rupture of the pectoralis major muscle, a rarity as compared with ruptures of other voluntary muscles. His study is based on the case reports in the literature, a number of which he summarizes, and two cases of his own. Heck A general discussion of the differential diagnosis of shoulder-arm pain is given by HORSIER (46) who outlines his treatment. He believes (a) that osteopathic manipulations are correct in a certain number of cases, (b) that x-ray treatment has some place, but it is useless to use more than six or eight applications, and (c) that head traction is still reliable, but if signs of compression persist after several months of conservative treat- ment (which rarely happens) it is necessary to advise laminectomy. BAUMANN (47) gives a dissertation on the anatomy of the cervical ver- tebral column from the point of view of its movements. He clarifies his article by diagrams. A technique of radiology of the cervical spine is described by SARA- SIK and GARCIA-CAIDEHDN (48). For the antero-posterior view, they recommend an ascending one at an angle of 20° from the horizontal which corresponds to the Inclination of the vertebral bodies. They state that when the angle Is correctly chosen the vertebral bodies are well separated and. the interverte- 233 bral spaces neatly recognized. They also recommend profile and oblique views. In discussing treatment, they mention ultrasonic therapy as the new- est, hut they have not had the opportunity to treat patients with it. They do not speak too enthusiastically about x-ray therapy. SAINT (49) presents numerous case histories, in the form of a clinical atlas, of swellings of the neck, primarily in the submaxlllary triangle. The cases include "brachial dermoid, tuberculous glands, late secondary syph- ilis, gummas, von Mickulics disease, lymphatic leukemia, Hodgkin*s disease, obstruction of Wharton's duct by a calculus, papillomata, hygroma, mixed tumors of the submaxlllary gland, secondary carcinoma in the submaxlllary gland, and multiple epltheliomata. The final case is that of a fibrous dys- plasia of the mandible with a large projecting extension filling most of the submaxillary triangle. Although a clinical diagnosis of sarcoma was suggested, microscopic sections reveal a typical structure of a fibrous dysplasia of bone. One of the disorders referable to the cervical spine, less frequently reported than others, is prolapse of the nucleus pulposus in the cervical re- gion, accompanied by compression of the spinal cord. ISBISTBR (50) discus- ses the condition and reports a case. The author maintains that the clini- cal picture of this syndrome does not appear in standard texts, and, there- fore, the diagnosis is undoubtedly missed frequently. The author briefly re- views the literature beginning with Adson (1925) and including Stookey (1929)* Schmorl (1929). and Andre (1929). The propensity of the lumbar and cervical regions to be the site of prolapsed discs is explained anatomically and is the reason for clinical signs often indicating a level one or two segments below the actual lesion. The pathogenesis is briefly mentioned with the two principal theories. The most frequent clinical feature is insidious onset of cord symptoms often preceded by root pain. Sensory loss and muscle wast- ing are minimal with root compression. A Brown Sequard syndrome is produced when the cord becomes compressed. The cerebrospinal fluid may show elevated protein and positive Quechendstedt test, but often it is normal. On roent- genography, certain points should make one suspicious of a prolapsed disc. Negative findings are more important here than in the lumbar area. A-P, lat- eral, and both oblique views are necessary. The value of myelography is not universally agreed upon. Other diagnoses to be considered are mentioned. Treatment is conservative in pure root lesions and surgical when signs of cord compression are present. One case is reported in detail, the patient having a sudden onset of pain and weakness in the right arm followed by par- esthesia in the left leg. A laminectomy was done, and a herniated nucleus pulposus was found and removed with almost complete recovery. The author describes the anatomy, pathogenesis, and pathologic roentgenographlc find- ings in prolapsed cervical neucleus pulposus. He describes a case in which the diagnosis was missed for six months, and he stresses the importance of being familiar with the syndrome. LIH7RB (5l) discourses on the pathology of the cervical discs from the points of view of symptomatology in cases of discs with different locations, diagnosis, and treatment. It is illustrated by two case reports. RICAED and GIRARD (52), in a paper entitled ”Cervico-brachial Neural- gias,” discuss cervical discopathles. The tests they consider important are the compression test of Spurling, which exacerbates the pain, and forceful traction, which relieves it. They outline orthopedic treatment as conslst- 234 ing of immobilization achieved by bed rest, a Minerva Jacket, a Thomas col- lar, or traction. They regard chiropractic maneuvers as dangerous. Surgi- cal treatment can be direct intervention by laminectomy, intervention at a distance by scalenotomy, and indirect intervention by sympathectomy and re- section of the occipito-temporal, and sometimes the external carotid, artery innervation. GrISPERT (53) writes on the possibility of confusing the diagnosis of amyotrophic lateral sclerosis with various processes which may compress the cervical spinal cord including ruptured discs. He has attempted to establish a diagnostic standard consisting of sensory tests as well as manometries and myelography. GrHERSI and FERRE (5*0 report a case of brachial neuralgia from protru- sion of the sixth cervical disc, treated by a combined neurosurgical and orth- opedic operating team by excision of the disc* Further case reports are pre- sented by RIZZO LI et al (55) and SHELDM and PDDEHTZ (56). Head and neck pains of cervical disc origin are discussed by SCHULTZ and SBMMES (57) and RANEY et al (5®)* The latter discuss four supposed sour- ces of posttraumatic headache and state evidence for or against each. They are: (a) intracranial structure, (b) the skull, (c) the scalp, and (d) cer- vical spin. The authors feel that much headache is due to ruptured cervical discs since in almost every instance of head trauma, some force is transmit- ted to the neck structures. They feel the headache is not produced by the disc primarily, but rather is secondarily due to mechanical factors involving surrounding structures. They feel that this type of chronlcity is in keep- ing with the slow healing of this structure. The authors conclude that post- traumatic headache is often unexplainable on the basis of scalp, skull, or intracranial lesions. The posttraumatic syndrome has been duplicated by in- jecting irritating solutions into the upper cervical and suboccipital regions. There is clinical evidence to support the cervical region as a locus for pathology-producing headaches. Cervical arthritis, myositis, flbrositls, and ruptured intervertebral discs are etiologic agents* OVERTON (59) reviews the literature on degenerative arthritic changes in the cervical spine with associated nerve root pain. This is followed by am analysis of 123 consecutive cases of cervical root pain. 78 report pain referred to the shoulder girdle or upper extremities, while seven present symptoms and objective findings to warrant a diagnosis of a ruptured inter- vertebral disc* Conservative management such as traction, good sleeping posture, heat, massage, and x-ray therapy has given very good results. Surg- ery has not been required in any of the cases. In two articles recording his findings in a clinical study of cervical rheumatism, COSTS (60,6l) classifies it as follows: (a) acute articular rheu- matism, (h) infectious rheumatism, (c) allergic rheumatism, (d) chronic poly- arthritis, (e) ankylosing spondylitis, and (f) cervical arthrosis. The last classification is subdivided into cervlco-brachial neuralgia, scapulo-humer- al periarthritis, reflex dystrophy of the upper extremity, night pain, thor- acic pain, and head symptoms. He discusses these various conditions from the point of view of anatomy with dermatome distribution and sclerotome dis- tribution of Kellgren. He also covers thoroughly the divergencies in treat- ment. 235 The existence of a syndrome known as the "stuck joint syndrome" Is postulated hy STONSHILL (62), said syndrome "being a possible explanation for such clinical entitles as headache, crick stiff neck, neuritis of the arm, occipital neuralgia, cervical radiculitis, the scalenus anticus syndrome, and the pathological disc# It is stated that the common origin of the above is a "stuck" posterior cervical joint, in other words, a joint whose motion is partially or completely restricted with or without gross anatomic or path- ologic findings in the Joint or its capsule. There are four clinical find- ings which direct attention to the possibility of the existence of a "stuck Joint," They are (a) restricted mobility of the cervical spine and pain on forced movement of the apophyseal joint, manifested on chin to shoulder, ear to shoulder, and chin to chest maneuvers, (b) pain elicited by palpation of the joint capsules which aids greatly in localization of the affected joint, (c) tenderness at the insertions of muscles arising in close relation to the joint, i.e,, levator scapulae and scalenus anticus, and pain at the occiput laterally and just below the superior nuchal line, and (d) radiographic evi- dence of deviations from the normal cervical spine, i,e,, altered normal spinal curvature, ill-defined joint interspace, rotated vertebrae, failure of the "stuck" joint to open as widely as normal in flexion or close as com- pletely as normal in extension, and distortion of the intervertebral disc. SHBBHAN (63) treats the affected muscles in acute stiff neck due to exposure to cold drafts with ethyl chloride spray to the overlying skin area. This is done in conjunction with massage of adjacent area, followed by grad- ual increase in range of motion. Of 30 cases, 29 are reported to have ob- tained complete relief in five minutes and one was worse the following day. BROWN et al (6*0 describe and advocate the method of excision of the entire sterno-cleido-mastoid muscle, rather than muscle section (myotomy), in selected persistent cases of torticollis. In a subsequent article in a different journal, BROWN and McDOWELL (65) reiterate their findings and con- clusions. A case history, as presented by PEIKOFP (66), represents the typical findings of the scalenus anticus syndrome, either with or without a cervical rib as a complicating factor. Symptoms and signs presented are subclavian artery insufficiency and compromise in normal function of the lower trunks of the brachial plexus as demonstrated by impairment of median and ulnar nerve function. It is of interest that early in her course the patient's condition was mis-diagnosed as ulnar palsy, but by demonstrating differences in blood pressure and radial pulse0 of the left and right arms, as well as positive Adson's maneuver, it became evident that the pathology lay more proximal than the left medial humeral condylar area. Description of scalen- otomy emphasizes the necessity of accurate identification of structures when doing dissection in the neck. This is especially true when separating the scalenus anterior from its insertion on the first rib so as to avoid injury to the subclavian artery posteriorly and the pleura medially. It is neces- sary to insure division of all muscle fibers so that the subclavian artery and/or involved nerves are seen to be free of pressure. In spite of marked muscle atrophy, paresis, and tendency of the patient to maintain "malnen- graffe" position of her left hand, rapid recovery is seen following scalen- otoray with perfect anatomical and functional result four years postoperatively. TINOZZI (6?) gives a scholarly discussion interpreting the work of auth- 236 ore in other countries with two case reports to illustrate the syndromes of the supraclavicular angle. ARSMI and MARCOVICI (68) report the results of 26 cases of spasmodic torticollis treated hy what they describe as posterior rhizotomy with amel- ioration in the majority of cases. KLIMA (69; reports two cases of torticol- lis ocularis. Pour articles on conditions which involve nerves of the cervical re- gion are reviewed. Brachial neuralgia is reviewed by PHILIP (70) in outline form with typical case presentations of h2 cases. The Importance of the neurocentral joint is stressed, differential diagnosis is discussed, and ther apy is outlined. In the JOURNAL DBS PRATICIMS (71) is outlined the conser- vative treatment of cervico-brachlal neuralgias as immobilization, traction, manipulation, medication, and physio-therapy. SILLE7IS (72) writes a short dissertation on brachial neuralgia Including the scalenus anticus syndrome, bumero-scapular periarthritis, and cervical migraine, SEPICH and SAGASTUME (73) report a case and discuss the medico-legal considerations of partial paralysis of the brachial plexus due to traumatic stretching. They also re- port a posttraumatic psychoneurosis in their case. The occurrence of a cervical rlh is discussed by POPPSN et al (7*0* They give a comprehensive presentation of the subject from the standpoints of anatomy, pathology, symptomatology, cad diagnostic aids. They analyze a series of 58 cases, including case reports of three cases of unusual inter- est. Non-operative as well as operative methods of treatment for this con- dition are discussed. Of interest is their analysis of 58 cases gathered from 115 cases of scalenus anticus syndrome seen over a ten year period. The preponderant number are females, in a ratio of seven to one. Operative procedures of rib resection, anterior scalenotomy, medial scalenotomy, and sympathectomy, performed at single or combined procedures, achieve good re- sults in 50 patients, while six show fair results, and two show poor results with no improvement following the operation. A history of trauma is obtained in 11 patients who previously had been asymptomatic. These seem to substan- tiate the statement that cervical ribs occur in 0.03 to 0.1 per cent of the total population, and that 5 to 10 per cent of these individuals are sympto- matic. In cases which do not respond to conservative, non-operative treat- ment, exercises designed to elevate the shoulders and bring them forward, thereby relieving pressure on nerve and vascular structures in the neck re- gion, are recommended. Surgical intervention in the forms previously des- cribed is advocated. Removal of the upper three dorsal sympathetic ganglia on the symtomatic side greatly benefits patients with marked vasomotor chang- es in the horaolateral extremity. WERTHEIMER and ALLERGRE (75) ascertain, from observations of nine cases of cervical syndrome, the Important role of the sympathetic factor in the genesis of vascular and nervous disturbances occurring in patients suffering from such a malformation. If anatomical lesions are missing, sympathetic surgery seems the best course. Rib resection alone is not able to bring re- covery. Six patients in their series show Improvement after sympathetic op- erations (periarterial sympathectomy, stellectomy, "under-stellectomy”). If arterial lesions, local or distant as shown by arteriograms, are found, ar- terial surgery is necessary. PUE7ES and WEDIN (?6) make an interesting report of a mother and fath- er who had 13 ribs on one side and 12 on the contralateral side. In the father, the cervical rib appears on the right, and in the mother, on the left. Five of 11 children have bilateral cervical ribs. All of these pa- tients are asymptomatic as regards their cervical ribs. 2 38 BIBLIOGRAHTT 1, Thatcher, H, 7,; A transacromial incision for exposure of the shoulder Joint, Am, J. Surg,, 78: 864-6, Dec 1949 2. Hoard, P., and Montagne, M,: The anterior humeral route, Med, trop., 10: 284-6, Mar-Apr 1950 3* Kessel, A, W, L,; Arthrography of the shoulder Joint, Proc, R. Soc, M., Lond., 43: 418-20, May 1950 4-. Warrick, C, K,; The lateral projection of the shoulder, Brit, J, Rad- iol., 23: 119-21, Feb 1950 5* Harmon, P. E,, Merryman, 0. 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D.: Recurrent dislocation of the should- er repaired by the Magnuson-Stuck operation. Arch, Surg,, 60: 11**0- 50, June 1950 25* Rucker, H., and Cavalcanti, M,; Treatment of old dislocations of the shoulder. An, paul, med, cir,, 59: May 1950 26. Castillo, Odena I.; Treatment of recurrent dislocation of the should- er by the Gallie-Lemeeurier technic, Bol. Acad, argent, cir., B, Air., 3**: 208-15, May 17, 1950 27. Coville; Treatment of recurrent dislocations of the shoulder, Acta orthop. belg., 16: 395-7, July 1950 28. Lepine, B,, and Langevin, R,: Recurrent dislocation of the shoulder. Union med, Canada, 79: 750-1, July 1950 29. Sohier, Tourenc, and Thevenin: Recurrent dislocation of the shoulder; operation of Picola, Marseille chlr,, 1: 531, Sept-Oct 19**9 30. Thompson, P, R., and Winant, E, M.j Unusual fracture-subluxations of the shoulder joint, J. Bone Surg., 32 A: 575-82, July 1950 31. Michaelis, L, S,; Internal rotation dislocation of the shoulder; re- port of a case, J. Bone Surg,, 32 B: 223-5, May 1950 240 32. Howell, T. H*j Suhluxation of the shoulder joint in chronic rheumatoid arthritis, Med. Illust., 4; 385-8, Aug 1950 33* Asherman, B. G,: Rupture of the musculo-tendlnous cuff of the should- er, J. Maine, M, Ass., 4-1 s 327-8, Aug 1950 34. Laduron, E.: A case of extensive destruction of the humeral head re- placed by a metallic prosthesis, Acta chlr. belg., —: 592-4-, Nov 1949 35- Miller, L, P., and Eilkevitch, A.: Osteochondritis dissecans of the shoulder. Am. J, Roentg., 631 223-7# Peb 1950 36. Tarrant, R. M,: The axial view of the clavicle. X-ray Technician, 21: 358-9, May 1950 37* Nathanson, L,, and Slobodkln, M.r Acromioclavicular changes in pri- mary and secondary hyperparathyroidism. Radiology, 55? 31-5# July 1950 38. Alexander, 0. M,: Dislocation of the acromioclavicular joint. Radiog- raphy, Lond., 15: 260, Nov 1949 39* Typovsky, K.; Extirpation of the clavicle, Rozhl. chir., 29? 109- 15. 1950 40. Stapelmohr, S. Von; Luxation of the sternoclavicular joint, Acta orth- op. scand., 19 : 243-6, 194-9 41. Reymond, J. C.: Acromioclavicular luxations, J. prat.. Par., 63: 590, Nov 10, 1949 42. Bohler, J. Von: Treatment of acromioclavicular dislocations with a temporary pin transfixation, Wien. Med. Wschr., 100: 265-7, Apr 22, 1950 43. Milch, H.; Partial scapulactomy for snapping of the scapula, J. Bone Surg., 32 A: 561-6, July 1950 44. Tbarz, P. j Wound of the axlllo-scapular pyramid hy imoale- ment. Arch. urog. med., 36: 101-3, Jan 1950 45. Hayes, W. M.; Rupture of the pectoralis major muscle; review of the literature and report of two cases, J. Internat. Coll. Surgeons, 14; 82-8, July 1950 46. Morsler, de: Differential diagnosis of pain in the upper extremities, Med, £ hyg., 8; 190-1, June 1, 1950 47. .Baumann, J. A.: Anatomy of the cervical spine from the point of view of its movements, Med. £ hyg., 8: 185-7, June 1, 1950 48. Sarasin, and Garcia-Calderoa, J.: Radiology of the cervical spine and indications for radiotherapy, Med. & hyg., 8; 187, June 1, 1950 49. Saint, C. P. M,: Swellings of the neck; the submaxillary triangle, 241 Afp. M. J., 23: 991-9, Dec 10, 1949 50. Isblster, J.: Prolapse of the nucleus pulposus in the cervical region, accompanied by compression of the spinal cord, with report of a case, M. J. Australia, 2: 910-4, Dec 17, 1949 51. Llevre, J. A.; Pathology of the cervical discs, Sem. hop.. Par., 26: 2679-84, July 26, 1950 52. Ricard, A., and Girard, P. P.; Cervlco-brachial neuralgias, especial- ly those due to cervical disk pathology, Paris med., 40; ili-vi, Jan 14, 1950 53* Gispert, Cruz: Amyotrophic lateral sclerosis syndrome due to hernia of cervical intervertebral disk, Clin, lahorat., 50: 47-53, July 1950 54. Ghersi, J. A., and Ferro, R.: Brachial neuralgia and medullary com- pression due to protrusion of the 6th cervical disk; operation; cure, Dla med., B. Air., 22: 788-90, May 8, 1950 55* Rizzoli, H. V., Wannamaker, G. T,, and Hayes, G, J.: Literal rupture of cervical intervertebral discs; a review of 14 surgically treated ones, Med. Ana. District of Columbia, 19: 295-303, June 1950 56. Shelden, 0. H., and Pudentz, R. H, r Ruptured cervical intervertebral discs, California M., 72; 156-8, Mar 1950 57* Schultz, E. C., and Semmas, R. E.: Head and neck pains of cervical disc origin. Laryngoscope, 60: 338-43, Apr 1950 58. Raney, A. A., Raney, R. B., and Hunter, C. R.: Chronic posttraumatic headache and the syndrome of cervical disc lesion following head trau- ma, J. Heurosurg,, 6t 458-65, Hov 194-9 59* Overton, L. M.: Degenerative changes in the cervical spine as a com- mon cause of shoulder and arm pain. South. Surgeon, 16; 599-608, June 1950 60. Costs, F.s Clinical and therapeutic study of cervical rheumatism, Med. & hyg., 8: 227-9, July 1, 1950 61. Costs, P.; Clinical aspect and treatment of cervical rheumatism, Med. & hyg., 8; 246-7, July 15, 1950 62. Stonehill, T.: The stuck joint syndrome in the cervical spine, Ann, West. M. & S., 3; 42**-6, Dec 1949 63. Sheehan, F. T.: Acute stiff neck; treatment with ethyl chloride spray, Med. Tech. Bull., Wash., 1: 7-8, May-Jun 1950 64. Brown, J, B,, McDowell, F., and Fryer, M, P,• Facial distortion in wry-neck prevented by early resection of the fibrosed stemo-mastold muscle. Plastic & Reconstr. Surg., 5: 301-9, Apr 1950 242 65* "Brown, J. B., and McDowell, P.: Wry-neck facial distortion prevented "by resection of fibrosed sterno-mastoid muscle in infancy and child- hood, Ann# Surg#, 131: 721-33* May 1950 66# Peikoff, S# S.: Scalenus anticus syndrome; scalenotomy, Manitoba M# Rev., 30r 3U-3, May 1950 6?* Tinozzl, P. P.s Syndromes of the supra-clavicular angle, Resenha din. dent., S. Paulo, 18: 407-15. Nov 1949 68. Arseni, C., and Marcovici, N.: Operative treatment of spasmodic torti- collis, Rev. st. med,, Bucur., 1: 213-9* Oct 1949 69. Klima, M,: Torticollis ocularis, Prakt. lek., Praha, 29: 408-10, Oct 20, 19^9 70. Philip, V, M.j Brachial neuralgia, Brit. M. J., 466Oj 986-9, Apr 29* 1950 71. Treatment of cervlco-brachial neuralgias* J. prat., Par., 63: 503-7* Oct 13, 1949 72. Slllevls, S, W, 0,: Brachialgia and lumbalgia, Ned. tschr. geneesk., 94: 1901-3, July 1. 1950 73* Sepich, M. J., and Sagastume, J. M.: Partial paralysis of the brachi- al plexus due to traumatic stretching; medico-legal considerations, Dla med., B. Air., 22: 766-8, May 4, 1950 74. Poppen, J. L., Kendrick, J. P., and Smith, W. P.: Cervical rib, Surg. Clin. N. America, 30 : 843-51, June 1950 75* Wertheimer, P., and Allergre, G.t Cervical rib syndrome, lyon chlr., 45: 565-74, July 1950 76. Purves, N. K,, and Vedin, P. H.: Familial incidence of cervical ribs, J. Thoracic Surg., 19: 952-6, June 1950 CHAPTER X7II FOREARM AND HAND By Brnst Dehne, Lt. Colonel, MC Letterman Army Hospital San Francisco, California Assisted By David Hull, Major, MC Duncan Sellers, Captain, MC I* The elbow and forearm A. Loose bodies B. Muscles C» Monteggla fractures D. Epicondyles B. Bony ankylosis F. Miscellaneous II• The wrist and hand A* Neurovascular B. Neuropathy C. Tendons D. Wrist joint 3* Carpal lunate F. Carpal scaphoid C. Carpal-metacarpal joints III. The hand and fingers A. Infections B. Hand surgery in general C. Skin plastic procedures D. Reconstruction of digits B, Duypuytren*s contracture F. Miscellaneous Out of World War I emerged orthopedic surgery in its present form. Out of World War II, surgery of the hand. Dp till then surgery of the hand was practiced hy individuals or furthered by groups like Sumner Koch and his coworkers in Chicago. But it was up to Sterling Bunnell to teach and estab- lish the specialty on a national and now international basis. Whether he be quoted or not, his principles are reflected in every one of the 100 articles which follow. The Elbow and Forearm Loose bodies of the elbow Joint are discussed by MORTON (l). He pro- 244 poses a classification into four groups: Group Is Loose 'bodies in pathological Joints (Osteoarthritis, neuro- pathic Joints, tuberculosis, acute infections). Group II: Loose bodies from tumor formation. Group Ills Loose bodies from congenital or developmental origin. Group IV: Loose bodies of traumatic origin. The literature covering the first reports on various conditions is reviewed and the article illustrated by three cases* The medicolegal aspects of one case of osteochondromatosis of the elbow are analysed by LIKO (2). He feels that trauma did not cause the condition but aggravated it. A case of osteochondritis dissecans of the supratrochlear septum of the humerus is described by VOH ROMES (3). Under the section of muscles is Included an article by SEDDOH (*0 des- cribing the transplantation of the pectoralls major for paralysis of the flexors of the elbow. The operation was previously described by Clark in 19**6. The lower one-third of the pectoralls with a continuous piece of rec- tus abdominis sheath is elevated. The separate blood and nerve supply of this portion is carefully preserved. A wide tunnel in the arm is necessary to maintain the blood supply of the transplant. The rectus sheath is anas- tomosed then to the distal biceps tendons. The angle of choice at the elbow is 30 degrees above the angle. 16 operations were performed with worthwhile to excellent results. GOOD (5) discusses a well known syndrome referred to as acroparaesthe- sla which is found usually in middle aged fatigued women, engaged in manual work. It is characterized by referred pain, paraesthesias, and so-called "myalgic spots'1 which are very tender to pressure. The author feels that it is an etiopathic myalgia and can be cured in a short time by injecting 1-2 cc*s of procaine accurately into each myalgic spot* Anterior Monteggia fractures according to EVAHS (6) consist of: (a) fractures of the ulna in its middle third, with backward angulatory deform- ity and anterior dislocation of the head of the radius, (b) fracture of the ulna in its middle third with a high fracture of the shaft of the radius, (c) anterior dislocation of the head of the radius without fracture of the ulna. The author is of the opinion that this fracture is produced by falling on the outstretched hand with the arm well pronated. Experimentally, the author subjected 18 forearms to stresses between a wooden clamp and vise to determine the mechanism of anterior Monteggia fracture. In 12 specimens he obtained a fracture of the middle third of the ulna, and dislocation of the head of the radius. 11 cases of Monteggia fractures were studied in this report. The treatment used by the author was that of placing the patient under deep anesthesia, pronatlon of the forearm, and manipulation of the head of the radius with plaster of Paris immobilization. Two of the patients in this series had to be operated upon for late treatment and epiphyseal sep- 245 aration. In 10 of 11 cases, a normal range of motion was attained. Poor function was encountered on the avulsed radial epiphysis. Next, the epicondyles are considered. MOHABS (?) points out that In animals from the reptiles to the apes, the "brachial artery and median nerve pass a suhepltrochlear foramen. In men, an atavistic deformity is found in about one per cent of the population consisting of a bony spur a- rising on the medial side of the humerus above the elbow and overlying the artery and medial nerve. The top of that spur extends into a fibrous wart which attaches to the humerus and completes the encirclement of artery and median nerve. Only very rarely does this deformity give rise to symptoms. In the case described here, a Latin American stenographer developed paraes- thesia in the median nerve distribution aggravated by pronation of the fore- arm. The symptoms subsided on a three weeks regime of short-wave diathermy and no typing. BIAHCHI (8) gives a lengthy review of tennis elbow with description of the condition and all possible and impossible theories that were ever ad- vanced for its etiology. Conservative and surgical treatment were reviewed. A questionnaire was sent out to 20k Italian championship tennis players of which 30 per cent suffered from tennis elbow at one time or another. The treatment consisted in reeducation to a different technique of tennis play- ing. RBYMOND (9) suggests that for the purpose of treatment, tennis elbow be divided into three groups. In the benign group, wearing of a sling, ap- plication of heat and use of novocalne infiltrations over a period of two weeks is advised. In the more severe cases, stellate ganglion blocks, x- ray therapy or the use of some of the European Spas is advised. In the re- bellious cases, stripping or resection of the epicondyle is advised. Other surgical methods consist in denervation or drilling of the bone. Two cases of bony ankylosis of the elbow are described by WBBBR and HUTA (10). These cases were treated by wide resection of the joint. One case is illustrated by x-rays only, the other one by photographs also show- ing full range of motion of the elbow. Caution is advised by WUSTMAM (11) in attempting to get motion in a stiff elbow for the well known reasons that an elbow arthrodesed in function- al position is more desirable than an unstable, painful, and movable one. An attempt at arthroplasty may be indicated in young adults with good moti- vation, however. The author mentions 11 cases he treated prior to World War II, by arthroplasty (according to Lexer) in cases of bony ankylosis, with fairly good results. A young surgeon during World War II was left with an ankylosed elbow but also with a supracondylar pseudarthrosis following a gunshot wound. He was able to continue surgery, with excellent elbow motion following resection of the head of the radius. Since then the author has performed 7-shaped, supracondylar pseudarthroses in Ik ankylosed elbows fol- lowing gunshot wounds. He covers the supracondylar portion with fascia, and permits a saddle joint to form. He depends on the wedge shape of the pseu- darthrosis for lateral stability, and the forearm flexers and triceps exten- sor for anterior-posterior stability. This gave good functional results without any incidence of later stiffening. 246 Only one miscellaneous abstract Is included. Patella cubiti, according to LE7INE (12), consists of a sesamoid bone located in the triceps tendon, presumably an aberrant sesamoid or a previously separated portion of the olecranon epiphysis. One case is presented. Six cases have been reported previously by three different authors. The Vrlst and Hand Neurovascalar conditions are considered first. FT5IDER et al (13) e- valuate patients operated on since 1929 for Raynaud's Disease or Raynaud's -Phenomenon in the Massachusetts Greneral Hospital* 20 patients were studied; 38 had dorsal sympathectomies only and 16 had both lumhar and dorsal sympa- thectomies. When studied six months to 20 years after operation, clinical recurrence was noted in per cent, laboratory evidence of vasomotor acti- vity was noted in 60 per cent and sudomotor activity in 61 per cent of the 75 upper extremities studied. The results after sympathetic denervation for Raynaud's Phenomenon of the lower extremity are better than the results aft- er operations in the upper extremity. Early recurrences are probably on the basis of anatomic variants which were not sectioned at the time of operation. LBINWAND et al (1*0 report two patients in whom Raynaud's Disease and hypertensive vascular disease were associated. One interesting point ob- served in the case presentations was that in both instances for the first hours following sympathectomy the involved fingers and toes appeared slightly more cyanotic and cold than prior to surgery. However, at the end of one week adequate circulation had again returned to the digits. A good result was reported in both cases. Raynaud's Disease of the hands with sclerodactylia is a brief and in- conclusive case presentation by BRUHSTIHG- (15)* BOULYIK (16) describes brachial block anesthesia and its complications; 25-30 cc's of two per cent solution of novocaine were used without adrenaline. This is considered to be safe from the toxic point of view. The incidence of pleuropulmonary complications is 0.1 to 0.2 per cent. Vascular corrrolica- tions were encountered on the basis of lacerations of the transverse scapula artery of the subclavian vein. Horner's syndrome is described as a compli- cation. (Ed: Production of a Horner's syndrome is certainly a transitory affair and not totally unexpected considering the anatomy of the area; to- tal dose of procaine recommended here is 0,5 gram approximately. One per cent novocaine is equally effective and reduces to a completely satisfactory level the total drug dose.) The first article considered under neuropathy is one by PHALEH et al (1?) who discuss neuropathy of the medial nerve due to compression beneath the transverse carpal ligament. This was first described by Marie and Poix in 1913* Their theory was based on findings at autopsy. The authors des- cribe three cases with four operations. The complaints were bilateral in all cases. The most reliable diagnostic signs were sensory distribution in the hand without atrophy and a Tinel's sign at wrist level. The presenting symptoms were pain, worse at night, but aggravated by exertion during the day, paraesthesia and weakness of grip. Three cases had immediate subject- ive relief from pain by splitting of the transverse carpal ligament. In two cases enlargement of the nerve proximal to the ligament was encountered. 247 Only one patient was operated on "both sides. (Ed; The cases appear well worked up, were adequately tried on conservative treatment prior to surgery and carefully reevaluated after surgery. Two more cases of the same condition were treated surgically hy BAL- LANTYNE and COWRIE (18). Symptoms and findings consisted of pain, weakness, and numbness in thumb, index, middle finger and volar aspect of forearm oc- curring when carrying heavy objects, when fatigued, and at night. These cases were bilateral. Treatment consisted of division of the transverse car- pal ligament. Exposure of median nerve revealed this structure to be edema- tous and injected. At followup, patients showed continued relief of pain and improvement in atrophy. KEHDALL (19) presents case histories of 14 patients with median nerve palsy. In eight cases the palsy could be traced to the occupation of the patient. These were all unilateral nerve palsies. In most of these cases the treatment was immobilization in plaster for a few weeks. The author noted that the abductor pollicls brevis is the muscle most affected by the wasting and that six of the eight cases had vasomotor or trophic changes. Six other cases are presented with bilateral nerve involvement. The author notes in comparing the groups that unilateral palsies are seen in the younger age groups and that the bilateral type is seen in the older age groups. The younger group is mainly male and in most cases a particularly strenuous typo of occupation is followed with evident trauma to the median nerve at the wrist. On the other hand, the older age group women, develop bilateral pal- sies as the result of fairly normal activities. WAT SON-JOKES (20) writes that the syndrome, pleonosteosls, described hy Leri consists of broadening of the thumbs, flexion contracture of the fingers, limitation of motion of the Joints, shortness of stature and mongo- lold face, Leri was impressed by the bone changes, particularly the large epiphyses of the phalanges. The author describes three members of a family who fall into this group and then another case, who, in addition, suffered from median nerve compression in the carpal tunnel and bilateral Morton's toes. Biopsy of the transverse carpal ligament revealed hypertrophic chang- es of the ligaments, Polease of the carpal ligaments as well as removal of the metatarsal neuromas resulted in symptomatic reliefs. On the basis of the pathological findings, Watson-Jones believes that hypertrophic changes of the ligamentous and capsular structures surrounding the Joints is the basic path- ology in Leri's pleonosteosls,. ROUNDTREE (21) submitted an article on anomalous innervation of the hand muscles. A number of earlier papers describing anomalous innervation of intrinsic muscles of the hand produced contradictory results. Those ear- ly papers were based on anatomical dissection. Following World War II, Mur- phey, Eirklin and Flnlayson analyzed the clinical findings in 398 ulnar and 555 median nerve injuries in regard to innervation of the muscles. After eliminating all unsuitable cases 102 median nerve lesions and 124 ulnar nerve lesions remained. Evaluation was meticulous and based on very rigid criter- ia. In many instances the good nerve was blocked out with novocalne to gain further information. In essence, it was found that the pattern of ulnar and median nerve innervation as described in the text books is the most commonly found pattern. (Ed: Although it is not specifically stressed by the author, it appears most striking that the opponens of the thumb is innervated by the 24 8 ulnar nerve alone in 20 per cent of the cases and supplied dual Innervation in an additional 16 per cent* The article represents a very clear, excel- lently illustrated summary of painstaking study*) BROOKS (22) advocates hone block for those cases of high nerve lesion where no tendon is available for opponens transplant and for those cases of severe cicatrix of the wrist which would afford too poor a bed for a tendon transplant* The author has a series of 16 cases of which he considers five successful, nine as considerably improved, and two failures* The greatest difficulty lies in maintenance of the correction and avoiding return of the thumb towards its original position of contracture* The author makes the point that full correction of contracture is necessary before attempting bone grafting* An operation for opponens paralysis of the thumb by HOWELL (23) con- sists of dividing the flexor pollicis longue tendon at the wrist, rerouting it around the dorsum of the proximal phalanx back to the flexor surface of the wrist, and then repairing it where it was severed* The sound principles and excellent results of the Warm Springs Founda- tions are thoroughly analyzed, clearly discussed and superbly Illustrated by GOIDNJffl and IRVBT (2*0* The material is based on 91 cases* In essence, T* C* Thompson's operation rerouting the sublimis tendon of the ring finger around the flexor carpi ulnaris to the base of proximal phalanx of the thumb has given 85 per cent excellent results in 73 cases* The difficulties aris- ing from weakness of sublimis or flexor carpi ulnaris, other muscle weaknes- ses of thenar and thumb, instability of MP Joint or carpometacarpal Joint, or contracture are classified and detailed answers are given* The Foerster- Bunnell bone block is reserved for functionally irreparable hands and used for cosmetic reasons only* Tendons are considered next and here SILER (25) states that in primary tenorrhaphy of the flexor tendons in the hand emergency treatment consists in control of hemorrhage, treatment of shock, avoidance of further contam- ination, and when indicated, chemotherapy and ant 1-tentanus therapy* Oper- ative treatment is carried out under general anesthesia with tourniquet control unless there is a contraindication. All flexor tendons in the palm except those in the vicinity of the metacarpophalangeal Joint are repaired immediately* It is thought better to suture the flexor profundus alone or the proximal flexor sublirais to the distal flexor profundus than to attempt approximation of both* Divided nerves require primary neurorrhaphy* The tendon suture method has been that of Mason and Allen, with Bunnell's method being used less frequently* After tenorrhaphy, the wound is closed even if it is necessary to use a skin graft* HAYS (26) stresses the well-known fact that the repair must be strong, and accurate, and that most important, there must not be an excess of scar tissue. He discusses the formation of scar tissue, nature of the wound, op- erative technique, Infection, and postoperative care. The removable wire technique is preferred with no additions to previously described methods* Untreated silk is used by FLYHN (2?) in flexor tendon grafts in the hand for the proximal anastomosis, catgut for the distal attachment. The four cases described include problems of first magnitude* Some of these re- 249 quired pedical grafts prior to the tendon transplant* All four cases re- gained full flexion. Grafts were used only for the index, long and ring fingers. For the thumb and little finger transfer of the fourth sublimis is preferred* A point was made to test the proximal segment and muscle for amplitude and motion. The author considers secondary tendon repair permis- sible up to two months after injury. Union is easily obtained in tendon suture, wrote PU1TERTAFT (28), es- pecially in the flexor tendons, but a freely gliding tendon is difficult to obtain. In the finger the author uses delayed free grafts, whenever both sublimis and profundus are cut* If only the profundus is cut and a good sub- limis remains, the sublimis is not disturbed; rather a thin extensor tendon of the toe is used to replace the profundus. In the thumb he uses either immediate or delayed tendon suture. If neither is practical a free graft elongation of the flexor pollicis longus, or a flexor sublimis unit may be used. On all free tendon grafts he uses a toe extensor with its paratenon. No splinting is used, except in children, postoperatively. Full evaluation of results cannot be made until nine to 12 months postoperatively. In com- bined nerve and tendon injuries at the wrist the trend now is to suture the tendons immediately and the nerves three to four weeks later. ISBLIN and LAFAUSY (29) in seeking a way to circumvent the difficulties in tendon repairs in "no-man's land," conceived the idea that since tendons need immobilization for healing, and since mobilization remained the key to preservation of function, that the logical conclusion would be to split the procedure into two operations: healing of the tendon, then tenolysis with immediate mobilization. The clinical results of this concept were disappoint* ing, but it permitted the basis for a fundamental study, both from the point of view of gross pathology and histology. It was noted at the first stage of the delayed repair that all the tendons showed degeneration from the point of severance proxlmally to the muscle itself. This was manifested by a glo- bular formation at the severed end, by yellowish discoloration of the tendon, and by a high degree of friability which permitted rupture of the tendon without significant force. Histological analysis showed that the degenera- ted tendons lost all their nuclei, the parallel arrangement of the fibers was disturbed, and the interspaces between tendon and paratenon obliterated. Extensive vacuolization throughout the tendon was noted. At the second stage, tenolysis, it was found that the healing was much better and stronger if steel wires were used and that the healing was poor and surrounded with granulomatous tissue when silk was used. The entire length of the tendon formed cicatrix. After freeing, the tendons frequently became stuck again. The authors then removed the entire length of the severed tendon out to the distal phalanx and replaced it with delicate woven steel cables. It still was not gratifying. The steel cables always broke at the level of the MP Joint, and though repair of the broken cable was not too difficult, it was noted that it had surrounded itself by a structure very similar in appear- ance grossly and histologically to a degenerated tendon. This in time formed dense adhesions. THATCHER (30) describes the use of facia lata strips for replacement of injured flexor tendons in the hand when more than one finger is to be re- constructed or in congenital absence of the palmaris longus tendon. The op- eration is done in two stages. In the first stage, the injured tendons are removed and tendon sheaths canalized with stainless steel rods. In the sec- 250 ond stage the fascial strips are transplanted into the newly formed tendon sheaths. The author re-emphasized that in the palm the subllmls and profund- us tendons must he severed well proximal to any adhesions in order to mini- mize postoperative adhesion formation. No statistics are quoted. The auth- or has used this operation for the past ten years with good results. ROUHIER (31) describes an operation for repair of the tendon of the long flexor muscle of the thumb which permits retention of the original ten- don since this tendon is superior in strength and shape to the flat and nar- row tendons of the toe muscles. To avoid complicating infection, the opera- tion is done after the wound of the thumb has healed completely. The proxi- mal tendon fragment is lengthened and advanced to span the site of the inter- ruption. The area of Z-lengthenlng is reinforced with the distal tendon seg- ment. A series of 138 grafts to the fingers performed on 118 patients are analyzed by BOTBS (32) based on the follow-up study of cases. The area discussed extends from the distal palmar crease to the flexion creases of the proximal IP Joints. The most significant factor influencing the results rested with the postoperative condition of the fingers. In the favorable cases, 10 per cent perfect results were obtained and 90 per cent of the cas- es could flex the finger tip to within one inch of the palm. In cases with considerable cicatrix no perfect results were obtained and only 25 per cent of the patients could bring their finger tip to within one inch of the palm. Stainless steel sutures were found significantly superior to the use of silk. Most of the failures occurred in cases in which silk was used. The palmaris tendon was preferable to the sublirais tendon as a source of graft. The author advised excision of the tendon sheath and pulleys wherever they were scarred. Of the cases, there were 10 failures, 10 further cases required secondary surgery. Tendon grafts for the thumb were carried out in 23 cases. It was found better to extend the graft from the finger tip to the forearm, rather than to use a shorter graft from the finger tip to the thenar eminence. Stenosing tenovaginitis involving the abductor polllcls longus and ex- tensor pollicls brevis tendon sheaths at the level of the radial styloid was described by De Quervaln in 1895• HALL and BERG (33) report 22 cases. Symp- toms were typical pain of gradual onset, localized over the radial styloid. Grasping and lifting were painful. Conservative treatment by splinting re- lieves the patient but frequently takes four months to two years. Surgery gives prompt relief with less economic loss. Under local anesthesia a trans- verse Incision is made, and the small sensory branch of the radial nerve Is isolated. The tendon sheath is split longitudinally to permit full release of the constriction. Early motion is encouraged and normal use urged as soon as skin sutures are removed. In 22 cases, complete relief was secured in two to six weeks. GUERIN (3*0 distinguishes three conditions: crepitating tenosynovitis, stenosing tenosynovitis, and trigger finger. The well known entity of trig- ger finger and De Quervain*s stenosing tenosynovitis are described and res- pond to surgery. The crepitating tenosynovitis, however, affects primarily the extensor tendons in athletes like basketball players and responds well to immobilization in plaster of Paris for a brief period of time. 251 15 cases with calcific deposits ahoat the hand and wrist (flexor carpi alnaris at the pisiform hone; flexor carpi radlalls at the greater multangu- lar and about the palmar aspect of the heads) are presented by SEIDMSTEIN (35)* The findings were severe pain and induration of the area of the de- posits; frequently they have been diagnosed as an infection until x-ray ex- amination was done* The symptoms may be relieved by: Plaster cast and pro- caine infiltration. Surgery is not necessary* The condition is a self lim- iting one and within three weeks the deposits fragment and disappear* There is no clue as to etiology* KASTEHT (36) feels that in the usual operation for wrist drop with transplantation of the flexor carpi ulnarls or flexor carpi radlalls, about one-half the strength of the muscle is wasted in a useless lateral pull. He feels that this is the reason for poor results* He suggests the flexor car- pi ulnaris be threaded through the extensor digitorum communis and extensor polllcis longus while the flexor carpi radlalls be threaded throng the ab- ductor pollicis longus* extensor polllcis brevis, and extensor carpi radlal- is longus. The ends of the transplanted flexor carpi radlalls and ulnarls are then anastomosed to each other. In this way, approximately all of the combined muscular pull is exerted in a useful proximal direction. The first of three articles on wrist .1oint is one in which a method of arthrodesis of the wrist is presented by THOMAS (37)* The medial surface of the distal end of the tibia was suggested as a donor site for a diamond shaped bone graft for wrist fusion. The advantage is thought to be in the curve of the graft which permits a cock-up position of the wrist without crowding the overlying tendons. The article describes the method alone, no cases are pre- sented* A case of dorsal dislocation of the distal end of the ulna was treated by fusion of the distal radio-ulnar Joint and resection of part of the shaft of the ulna proximal to the fusion by 7ERG0E (38)* BUSSELL (39) reviews 59 cases including a comprehensive discussion of every injury to the wrist. In recurrent subluxation of the navicular, the best results are obtained by closed reduction followed by mobilization exer- cises. Excision of fragments offer no advantage. Bone grafting of the nav- icular gave disappointing results. The persistence of x-ray pathology, non- union, aseptic necrosis or even unreduclble deformity does not preclude a good functional result. The ultimate result appears dependent on the time the injury is treated. Median nerve paraesthesia Is the outstanding sign of dislocation of the lunate* Carpal lunate section includes an article in which DOHNAN (40) discus- ses Kienboeck's disease. This author reviews his experience with 43 cases which were observed over a ten year period. He does not confirm the theory of ulnar shortening. 63 per cent were treated by excision of the lunate ex- cept one which received an arthrodesis. The rest were treated by immobili- zation for a period of three to four months* The author concludes that re- sults of conservative and surgical treatments were very similar* JAMES (41) reports a case of rupture of f lexer tendons secondary to disease. A 50 year old truck driver had a nine year history of wrist pain. Four months prior to hospitalization he noticed loss of active 252 flexion in the distal Joint of his index finger* Three months later his hand suddenly became cramped and when the cramp subsided, the flexor function of the interphalangeal joint of the thumb was gone* Exploration of the car- pal canal revealed ruptures of both tendons and a perforation of the anterior capsule of the joint overlying the lunate through which six small loose bod- ise extruded* Tendon function was successfully restored, by reconstructive surgery* A case of bilateral Kienboeck's disease was reported by SOBEL and SOBEL (h2) and has been reported in only six other instances* This author's case was a h3 year old woman who had discomfort for six months without trauma. The x-rays revealed areas of radiolucency in both lunates* There was no col- lapse of either lunate. (Eds All that can be said with certainty about this case is that bilateral lesions of the lunate are present. It is felt that further chemical and skeletal studies would have been of interest and that this may not necessarily represent true Kienboeck's disease.) LIPPMAH (h3) makes a preliminary report of replacement of an excised lunate by a hollow vitallium replica* The patient was followed for 79 days post operatively. At that tine, he had returned to his occupation as a plas- terer. The pain had been relieved three days after surgery but his wrist remained slightly enlarged and the forearm somewhat atrophic* Lunates and perilunate dislocations, states AMERSTHT (hh), are the most common of the carpal dislocations, and are produced by a forcible dorsi flexion and a powerful thrust on the extended palm. They are usually asso- ciated with fracture of the navicular or the styloid of the radius* Of sev- en cases, only one was successfully treated by closed reduction. In recent cases open reduction was easy and the results are good. The author placed the cases in slight volar flexion for one week as dorsiflexion or neutral position caused the lunate to slip out of position. The fracture of the nav- icular when present does delay healing and the author felt that the associa- tion of the dislocated lunate had a bad effect on the healing navicular. He believes that open reduction is the method of choice and that a delay of even five weeks has no effect on the end result. Under carnal scanhoid is an article in which VAUGH and SULLIVAH (h5) write that among anomalies of the carpus the bipartite navicular is the most common* Gruber in 1865 described four bipartite naviculars in a review of 3002 carpal scaphoids. The author describes two cases of bipartite navicu- lar which occurred bilaterally. (Ed: There is no good reason listed in the article why these roentgenograms should not be called non-union of the navi- cular except for the fact that the x-rays were read by Dr. Albert D. Fergu- son of Boston and that his precise and sharp analysis of the findings lends that questionable entity considerable weight.) D¥YER (h6) alleges that considerable progress has been made with non- union of the carpal scaphoid. Age, presence of arthritis, and associated subluxation of the lunate were considered as factors influencing the outcome of the 19 cases. 12 were good, h were fair, and 3 were bad. "Trial exci- sion" is recommended since it can be followed by arthrodesis if unsuccess- ful. Excision of the proximal pole alone is considered inferior to total excision. 253 HAGEN (4?) describes one case of dislocation of the scaphoid and re- views the literature. The first case of that nature was described by Fwing in 1921. A total of five cases has been reported since. All those previous cases healed with poor results and reduction was not possible in most of them. The author’s case was a compound injury resulting from a fall. The navicular was displaced anteriorly and x-rays revealed a separation from the lunate. The dislocation was reduced under local anesthesia ten days after injury and immobilized in a cast for four weeks. Subsequently, full func- tion of the hand was obtained. 1 case of recurrent subluxation of the scaphoid is reported by VAUGHAN and JACKSON (48). The condition developed in an athlete following a sprain. It was characterized by local pain on flexion of the wrist and by an audible click upon rapid dorsiflexion. X-rays taken at rest were unrevealing. The patient, however, was able to voluntarily maintain the subluxation and then the most striking feature was a wide separation between the navicular and lunate. He was able to control his condition so well that he did not feel that there was any need for further therapy. DSSSS and MINET (49) report a case of osteolysis of carpal scaphoid. Ramazzini in 1first described swollen wrists occurring in bakers who had been in their profession for a long time. The author further quotes Gruber who in I865 described bipartite naviculars allegedly resulting from separate ossification centers and Dupuytren who found arthritic changes in workers on printing presses, diamond cutters, pharmacists (from rolling pills), harpists and violin-cellists. He finally quotes Volkner, who referred a baker with sore wrists to Dr. Osgood. He had a bipartite navicular but this was blamed on a gonorrheal infection. The author’s case is a 49 year old baker, who had been in the profession for 38 years and noticed progressive difficulty with his wrists for the past five to six years. The x-ray appearance was one of non-union and the author calls it bipartite scaphoid without any oth- er positive proof except the absence of known trauma. He then studied anoth- er 19 bakers who had been in the profession for a long time and found one more unilateral non-union of the scaphoid, but some degree of arthritic al- terations in all the other cases. CAFFAHATTI (50) reports a case of congenital bilateral bipartite car- pal scaphoid. AVENIHR (51) describes all the methods of treatment for non-union of the navicular which he had abandoned. Carpal-metacarpal J0ints are represented by five articles. Osteoarth- ritis of the trapezio-metacarpal Joint is discussed by LASSFHRF et al (52). The best x-ray view of the trapezio-metacarpal Joint is obtained by having the patient kneel next to the x-ray table. The forearm and hand are then placed in maximal pronation so that the snuff box comes to rest on the film. The changes of osteoarthritis are described. The painful Joint should be immediately immobilized to prevent further development of arthritis. For this, an illustration of a welL-fltting splint is Included. A method of reinforcement of the first carpo-metacarpal Joint by pass- ing the fascia lata through drill holes is described by MICHFLF et al (53)• The method is recommended for traumatic luxation, malunited Bennett's frao* 254 ture and osteoarthritis with subluxation. Three cases with short preoperative history of local complaints and no serious attempt at conservative management by immobilization were relieved by this procedure. Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint was carried out 18 times on 15 patients by GEPVIS (54), The technique of operation is meticulously described. The results were uniformly excellent and gave complete relief of symptoms with a surprising degree of stability of the thumb in all but two cases in which there was generalized involvement of the hand. The author prefers excision to arthrodesis, stating that arth- rodesis is difficult to obtain, MULLER (55) prefers arthrodesis to excision. He claims that you can excise the bone only once, but in fusion, you can repeat the procedure if it has not turned out satisfactorily. The operative technique appears much simpler than excision of the bone. A simple inlay graft is used and the thumb immobillzred in a cast for four months. In eight cases perfect fusion was obtained. The patients were relieved from pain, regained a very strong grip and an excellent range of motion which is illustrated by convincing photographs, A case with dorsal dislocation of the second, third, and fourth meta- carpals and volar dislocation of the fifth metacarpal is described by G-IBAUD and 7ITT0HI (56), It was noted that the motor branch of the ulnar nerve was not affected. The Hand and Fingers The first article abstracted under infections of the hand and fingers is one concerning infection of the flexor tendon sheaths of the hand treated previous to the days of antibiotics and $0 cases since the advent of anti- biotics presented by ELTNN (57)* He points out that acute suppurative ten- osynovitis is decreasing in frequency. There has been in recent years a further decrease in the Incidence of suppurative tenosynovitis. In 12 cases were seen in the Boston City Hospital. In 1948 only six cases were seen. With antibiotics as an adjunct to surgery the number of good results has been more than doubled and the number of poor results is about one-third of what it was before the use of antibiotics. Puncture wounds have been found to be the most common type of injury causing septic tenosynovitis. The primary site of infection in 50 per cent of the cases was the transverse volar crease where anatomically the tendon sheath is devoid of its fibrous layer. Blind irrigation may cause extension of the infection. The author advocates adequate Incision and drainage of all recesses of the Infection together with parenteral administration of penicillin, A series of 50 unselected cases of pulp space infection was compiled in 1947 by BOLTON et al (58). All cases were operated and pus was found in each instance. The procedure of choice was a small eliptical skin excision accurately overlying the abscess. The cases were grouped into simple felons, 39 cases, which had an average healing time of 11 to 15 days, five cases where bone invdvement was suspected but could not be proved, with average healing period of 25 days; and six cases of verified bone infection with av- erage healing period of 35 days. Penicillin was used locally in three cases of osteomyelitis intramuscularly but not in an attempt at non-surgical man— 255 agement. (Ed: Efficacy of the antibiotics was apparently not enou^i at that time to encourage non-surglcal management.) SAMUEL (59) claims transIllumination of the finger tip to be a valua- ble adjunct to the diagnosis of infection. Pus, as well as tissue slough, throws a definite shadow. This is considered helpful in deciding when and where to incise in acute infection. Chronic infection and paronychia are described. In order to get accurate information it is necessary to ly cleanse the hands.. Her# surgery in general is considered next. In a comparative study of silk and steel sutures in repairing dog tendons the steel sutures were found superior by CARON (60) who states that they caused less inflammatory reaction and thus a more uniform scar capable of greater tension. However, steel su- ture material has a tendency to cut the tendon tissue and this disadvantage was overcome by using a very fine caliber wire. (Edr Fine braided wire has greater tensile strength and less tendency to cut through.) METER (6l) has altered the Allen and Mason universal aluminum splint described in 194? by making a wooden mold of the Alien-Mason splint and us- ing plaster of Paris, thus permitting greater variation in the extent of individual finger immobilization. JENKINS (62) advocates the adhesive strapping of a recently sprained or dislocated finger to the adjacent uninjured finger. In so doing, one has an effective splint and if strapping is applied loosely, motion is possible and stiffness is avoided. The method may also be applied to stable fractures of the phalanges and metacarpals. BERNHARD (63) points out the important fact which is not considered by all who treat finger injuries, that the Injury appears small, the disability to the proximal IP joint sometimes persists for a long time. The author mentions six case histories in which this was so. One was a minor sprain with slight discomfort remaining after 14 years. A similar disability resulted from cases of fractures of the proximal end of the proximal phalanx. Adequate splinting in the physiological position followed by active, and not passive, motion is recommended. Functional position and spring assisted functional motion is stressed by BUNNELL and HOWARD (64) along with the resistive exercise. The reader is referred to the excellently illustrated article for detailed description of these modifications of the time honored "knuckle-bender" splint. TUCKER (65) emphasizes early, gentle, active exercises without strain in treatment of traumatic conditions of the fingers, hand and wrist. Every effort is made to disperse traumatic effusion; e.g. elevation, contrast baths, faradic stimulation of muscles, aspiration or Incision where indicated. Specific injuries are described and discussed. BUNNELL (66) presents a paper designated for the occupational thera- pist, reviewing functional anatomy of the hand, splinting, specific function- al problems, as well as psychological applications. All reconstructive surg- ery should be completed prior to institution of occupational therapy. This is an excellent review for the orthopedic surgeon prescribing occupational therapy. 256 KESTLER (6?) has had considerable experience in reconstruction of hands crippled by rheumatoid arthritis. His approach is conservative, the cases are extremely well worked up. 11 cases of resection of metacarpal heads were followed over a period up to four years, eight months. A portion of the surgical success was ascribed to shortening of bony elements and preservation of the articular portion of metacarpals with placement of these over shortened shafts. BUEE (68) discusses the principles of hand surgery dealing with eval- uation of each digit and its importance; the principles governing the sutur- ing of tendons, nerves and skin in the hand and with the general technique and peculiarities about hand surgery. The author apparently is the Bunnell of Switzerland and in his bibliography only Bunnell and he himself are men- tioned, There is nothing in it that could not be found in Bunnell's text. LIEBOLT (69) states that the collateral ligament of the HP Joint is tense in all positions of the Joint while it is commonly accepted that the ligaments are relaxed in extension and tense in flexion. Apart from this, the technique of capsulectomy is the one described by Bunnell, This opera- tion has been performed by the author in 11 cases gaining JO to 90 degrees of additional flexion as a result. An important point is made—that of the motion gained at surgery, about 20 degrees is usually lost again. Two cases of arthroplasty are presented; one by resection of the metacarpal head, with full return of motion and another case with resection of the base of the pha- lanx with improvement of motion. RUBIN et al (70) deal with scar contraction along the flexion creases. Breaking up of the scar line is accomplished by Z-plasty or variations there- of . The work was done at Kings County Hospital in Brooklyn and includes ex- cellent illustrations. BRUNER (?l) advocates the use of an old fashioned buttonhook for frac- ture reduction in hand surgery. Observation of strict plastic principles, preservation of digital length, and adequate coverage of functional elements have been stressed in skin plastic procedures. STENBERG (72) favors full thickness grafts as re- placement for amputated fingertips. The importance of maintaining compres- sion for at least three weeks is emphasized. In 29 out of 37 cases, there were 100 per cent takes, in seven cases there were 75 per cent takes or bet- ter, with still excellent functional results and only one case was a failure due to infection. Transdigital flaps, according to GURDIN and PANG-MAN (73)* similar to cross-leg flaps, have been used in cases where bone or tendon is exposed, where adjacent fingers are not injured and when the defect is not too exten- sive for adequate skin to be obtained from a donor finger. Plastic princi- ples must be adhered to with emphasis on avoiding crossing flexion creases. The donor defect is covered primarily by a split skin graft. Pedicles have been severed between the and 21st days. No flap has been lost in six cases reported. The interdependence of satisfactory skin coverage and repair of struc- tures, sensory, and motor elements, is stressed by MACOMBER (7*0* Free grafts 257 mast not "be ased as final cover over tendons or joints not protected by a gliding mechanism* Specific indications for uses of free grafts, pedical grafts and flap shifts are listed. FUCHS (75) reports that in Id of patients recently subjected to plastic surgery, skin transplantation for prophylactic purpose was done im- mediately or within a month after trauma. All variations in degree and ex- tent of burns were represented in this material. Postoperative contractures included five of the shoulder, Z-plasty was done either alone or in combin- ation with other treatment in 28 of the Wl cases. Under reconstruction of digits, a case of thumb reconstruction by trans- fer of the big toe was reported by CLARKSON and FURLONG (?6) in a girl who at the age of three years lost all but the proximal phalanges of her fingers and the thumb. At the age of nine the big toes of the same side were grafted onto the first metacarpal. As preliminary operation a flap with distal ped- icle was raised on the foot. After the actual transfer, the hand remained sutured to the foot for six weeks. After two weeks the medial nerve vessel bundle of the toes were severed, at four weeks the lateral bundle, and at six weeks the full transfer was completed. The patient suffered no ill ef- fect from the removal of the toe and continued her participation in sports. The thumb remained viable but further surgery consisting of the attachment of the flexor tendon and anastomosis of the nerves and a bone graft to ob- tain union in the junction of the bones is still contemplated. A case of substitution of fingers is reported by ROSFNSTFIN (77)• The patient was a pianist who lost her long finger. The cicatrix incident to that loss prevented her from playing octaves. The second toe was substitu- ted for the long finger in two stages. Bones, tendons and nerves were joined and apparent function resulted. The degree of function is not specified ex- cept that the pianist will return to her occupation and play octaves. GRAHAM et al (78) present a method of restoring grasp and pinch after the loss of all digits, A hand without digits has lost its three major func- tions: grasp, pinch and hook, A prosthesis never functions as well as a hand with sensation. If the ability to pinch or grasp can be restored be- tween two opposable areas which have sensation, then a great portion of the hand function will be preserved. Their method consists of digitization of the first metacarpal bone, since the first metacarpal phalangeal joint is the only one with appreciable circumduction motion. Two essentials for use- ful digitized first metacarpals are; adequate depth of the cleft and ade- quate length to the movable portion. The second metacarpal is used for in- creasing the length of the first metacarpal. The long flexor of the thumb should be attached to the first metacarpal. The interosseus muscles between the first metacarpal and third metacarpal should be utilized to increase the pinch strength of the digitized metacarpals. Five cases illustrating this method are presented. The method is especially useful in individuals who have poor eye sight since the use of a prosthesis for a partially blind in- dividual is a great handicap. They state that a better functional result can be "obtained by this method than with available prostheses. D'AUBIGNF et al (79) report that in three cases the missing thumb was substituted by the remainders of an also injured index. In another five cas- es a new thumb was built by abdominal pedicle carrying an iliac bone graft along with it. HUGHES and MOORE (80) give a preliminary report on the use of a local flap and peg hone graft for lengthening a short thomh. Their two patients had sustained traumatic amputation of the left thumb at the metacarpophalang** sal joint. A cap of normal skin over the amputation stump of the thumb was retained in both. The entire flap was undermined and raised from the meta- carpal bone. Next, a block of bone with periosteum attached cut from the iliac crest and shaped to resemble a metacarpal, was firmly impacted into the metacarpal bone of the thumb. The skin flap was transferred over the bone graft and split thickness graft was sutured in place over the raw area. MITHOEFER (81) discusses Injuries limiting the mobility of the thumb and states that the mobility of the thumb depends on three factors: (a) the integrity and liberty of action of its musculotendinous apparatus, (b) the proper alignment of its bones and the mobility of its joints, and (c) the redundancy and elasticity of the skin and subcutaneous tissue of the thumb’s web space. The article includes five case reports illustrating loss of thumb function resulting from fractures with healing in poor position, injuries to muscles related to the thumb with their tendons, and soft tis- sue injuries resulting in contracture of the web of the thumb. The article discusses methods for relief, and improvement of these conditions. Surgical principles stated are standard surgical principles. HOWARD (82) outlines the treatment of contracture of the thumb web. The fundamental hinge to hinge principle is established. Skin replacement after release of contracture has to straddle the web from the dorsal aspect of the carpometacarpal joint to its volar aspect. This is convincingly il- lustrated by a variety of excellent reconstructive results.. An interesting antropological study by HARRIS and JOSEPH (83) measures the variation in extension of the metacarpophalangeal and interphalangeal joint of the thumb in 132 white males and 100 white females, 31 Indian males, and 30 West African males. Slight differences between the males and females as well as right and left side were established. An inverse ratio between the MP and the IP joint was found. Influence of musculature, capsule and bony structure on the range of motion is discussed. Dupuvtren13 contracture! Recent suggestions for the treatment of fi- brosis of the palmar aponeurosis include the shifting of a dorsal pedicle flap and the use of vitamin S* None of the authors point out the occasional occurrence of a similar process in the feet of afflicted individuals. The loss of flaps and skin coverage continues to be troublesome. BRUNER (84) recommended the use of a dorsal skin flap for the coverage of palmar defects after aponeurectomy for Dupuytren's contracture. In ad- vanced cases, subcutaneous fat is displaced and even skin may be invaded by the proliferating palmar fascia resulting in loss of skin at the time of ex- cision, Skin shrinkage after prolonged flexion contributes to the problem of adequate skin coverage. The author advocates the shifting of a dorsal pedicle flap in such cases. The mid-lateral line of the ulnar border of the hand forms one side of the triangular flap; the apex of the flap lies proxi- mal to the middle joint of the fifth finger. The donor defect is covered primarily with split skin. Careful plastic principles must be employed. 259 A series of 13 cases comprising 22 hands treated with vitamin E for Dupuytren's contractures is analysed hy THOMSON (85)* The review of the literature reveals divided enthusiasm, an equal number pro and con. The therapy consists in daily administration of 300 milligrams of mixed vitamin E or 200 milligrams of ephynal. Perhaps vitamin E therapy will prove effi- cacious in early cases and in preventing postoperative recurrence, Earlier work disputes its use in advanced cases. GRAY and DE TARNOWSKY (86) quote extensively from Bunnell regarding the diagnosis, pathogenesis and pathology of Dupuytren’s contracture. Their experience in two patients (total of three hands) is described in detail. In each of the three cases, some of skin appeared postoperatively be- neath a hematoma. This occurrence points to the need for hemostasis and pressure dressings in the management of this condition. RUMMEIflARDT (8?) reviews the etiology, pathology, and describes the ex- cision through longitudinal incisions of Dupuytren’s contracture. Recurren- ces appeared in 25 per cent. The work of Thoraanek, who used radium therapy, is referred to. 50 operative cases were reported by WENZL (88) with per cent regain- ing full function, 16 per cent good results, and 10 per cent bad results. Nothing new in technique is offered. In a discourse on Dupuytren's disease PAILLOT (89)* aside from giving the generally known pathology, describes subluxation of the IP Joints in ad- vanced cases, as well as sclerosis and shortening of the digital blood ves- sels, In addition to current and past pathogenic theories where emphasis is placed on its occurrence in various diseases of the spinal cord, Lerich's and Young's theory of connection with parathyroid dysfunction is mentioned. The treatment is divided into conservative and surgical. Of interest is the em- phasis on stellate ganglion blocks and the inclusion of sympathectomy or par- athyroidectomy amongst the conservative approaches. The author is reservedly satisfied with the results of early surgery for Dupuytren's disease but feels that disability has to be accepted in late cases, (Mr He practices in one of the European Spas, where many terminal stages of arthritic deformities are concentrated. It is obvious that he deals with a number of very severe terminal phases that are not commonly seen in our practice.) Under miscellaneous are grouped ten articles. Cyst-like changes In the small bones of the hand are described by OOSTHUIZEN (90), He lists 1? of the most common causes as follows: (a) chronic gout, (b) tuberculosis, (c) Boeck's sarcoid, (d) chondroma, (e) implantation dermoid, (f) glomus tumour, (g) secondary deposits, carcinomatous and melanomatous, (h) blasto- mycosis, (i) yaws, (j) hydatid disease, (k) compressed air drill disease, (l) osteoarthritis, (m) osteitis fibrosa cystica localisata, (n) bone cysts, (o) polystotic fibrous dysplasia, (p) injury to cancellous bone, (q) occa- sionally hyperparathyroidism and neurofibromatosis. No conclusions were drawn. A case of hamartoma of the hand was reported by COVENTRY et al (91)* Hamartoma was described by Albrecht in 190*4-, It is a name for a tumor-like malformation of congenital origin. It is not considered a true neoplasm. In most instances this condition has been found or claimed to be found in lungs, liver, kidneys, or spleen. The case described here is the one of a 69 year old woman with a three year history of tumor extending into the palm. The incapsulated tumor originated between the 3rd and hth metacarpals and was delivered through a palmar incision. It contained various connective tissue elements including precartilaginous and cartilaginous tissue and meta- plastic bone. Lipomas of the palm are exceedingly rare with only 11 reported to the date of this paper. BOSCH and BERNHARD (92) present the second recorded case in a negro. The patient presented herself with the complaint of a painless, progressively enlarging swelling of the palm interfering with the function of the fingers. At operation an encapsulated lipoma was found attached to the sheath of the flexor polllcls longus. Pathological diagnosis was lipoma. FRANCON (93) discusses the hand in gout. He states that gout usually starts with the big toe and finally reaches the upper extremities after 10- 15 years. He describes acute and chronic forms. Fine out of 26 cases were associated with Dupuytren's contracture and in the late stages, lesions of nails, eczema, psoriasis and x-ray changes were noted* JOLT (9*0 discusses the hand in chronic inflammatory rheumatism. The French term of polyarthritis, chronic, progressive, of Charcot appears to be a synonym for our rheumatoid arthritis. A very vivid description of clin- ical and pathological manifestation during the phases of development and full establishment of the disease is given. No new suggestions for therapy are given* SORREL (95) reports a condition resembling Tolkmann's contracture of the hand as the result of extensive osteomyelitis in childhood, binding down the flexor tendons. The fingers could be extended with the wrist flexed, but in forced extension of the wrist the MP joints could not be extended. The author planned to correct the condition under anesthesia. To his sur- prise, he found that anesthesia completely relieved the condition. He spec- ulates that reflex muscle spasm may have been one of the etiological factors operative in establishing the contracture* FELSENSTEIN (96) reports a case of a 1? year old girl diagnosed as chronic nephritis because of severe hypertension, enlargement of the heart and microscopic hematuria. Flexion contractures of her fingers, which had developed during the past six months, were considered to be on a preuremlc basis* DESSB (97) reports a case of Thlermann1s disease* The patient had pain- ful swelling of fingers aggravated hy rain and cold. The affected proximal IP joints presented a hony deformity. The proximal phalanx formed a male wedge received hy a corresponding female notch at the proximal end of the middle phalanx. In this case the condition was associated with intracranial pressure and hydrocephalus. KONAR (98) presents a case of dystrophia myotonica with a failure to relax the grip after a handshake. The case presented had cramps in the hand, inability to relax the grip and peculiar spasm of certain muscle groups, the deltoids, biceps, triceps, and quadriceps. There was simultaneous contrac- tion of the flexors and extensors of the arms and the thighs. In addition 261 there was loss of hair of the head, face, axilla and pubis, and impotence* The patient was treated with quinine sulphate and experienced considerable relief of the myotonus and the involuntary spasms. He left the hospital be- fore the effect of the prostigmine could be evaluated. CURTIS and KIRKMAH (99) compiled for dentists and oral surgeons a 6? page treatise illustrated by 59 excellent photographs covering the entire dermatology of hands and nails including infection, fungi, neoplasms, and radiodermatitis. Two cases of habitual locking of a metacarpophalangeal joint by a col- lateral ligament are reported by LAHGH5KI0ID (100), Heretofore, the cause of a "trigger finger" has been variously attributed to incongruity of the articular surface and hourglass deformity of a flexor tendon sheath. The author, in the present communications, adds a new concept of the mechanism of a snapping finger. In both of the cases reported by the writer, it was found that the radlovolar collateral ligament of the metacarpophalangeal joint of the index finger had been luxated and caught on the abnormally de- veloped capitulum of the second metacarpal bone. Trauma and focal infection (tonsillitis) were considered as contributory causes of the bony abnormality. Both patients had been subjected to exploratory arthrotomy, the respective lesions had been corrected and the trigger phenomenon had been abolished. The author states that a perusal of the available literature failed to show similar case reports. Interestingly, the second patient had to have his collateral ligament severed because it had projected Itself into the joint and hitched onto the volar metacarpal articulation with the pro- duction of locking and snapping. Recurrence has not been noted in these two cases. BIBLIOGRAHIY I, Morton, H, S,: Loose bodies of the elbow Joint, McGill M, J,, 18: 263-6, Dec 19^9 2* Lino, D. B,: Case of articular osteochondromatosis of the elbow with special reference to the medico-legal aspect, Minerva med,, Tor., 41: 524-6, 31 Mar 1950 3* Von Ronnen, J. F,: Osteochondritis dissecans of the supra-trochlear septum, Med. mbl,, J: 140-2, .Apr 1950 4. Seddon, H. J.: Transplantation of pectoralis major for paralysis of the flexors of the elbow, Proc. R. Soc, M,, Lond,, 42: 837, Oct 1949 5. Good, M. G.: Acroparaesthesia; an idiopathic myalgia of elbow, Edin- burgh M. J,, 56: 366-8, /ug 1949 6. Evans, F. 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W,, and Lord, J. W,, Jr.: Hypertensive vas- cular disease associated with quadrilateral Raynaud’s disease treated by total sympathectomy, Surgery, 26: 1034-43, Dec 1949 15, Brunsting, H, A.: Raynaud's disease of the hands with sclerodactylia. Arch, Derm. Syph,, Chic., 6l: 880-1, May 1950 16, Boulvin, P,: Anesthesia of the brachial plexus, Scalpel, Brux,, 103r 723-8, July 22, 1950 263 17. Phalen, G, S., Gardner, ¥. J., and La Londe, A. A.: Neuropathy of the median nerve due to compression beneath the transverse carpal ligament, J. Bone Surg., 32 A: 109—12, Tan 1950 18. Ballnntyna, D. A., and Comrie, E. Y.: Spontaneous compression of the median nerves in the carpal tunnel, N. Zealand M. J*, h9: 1*44-6, Apr 1950 19. Kendall, D.r Nonpenetrating injuries of the median nerve at the wrist. Brain, 73J 1950 20. Watson-Jonos, H.s Leri's pleonosteosis, carpal tunnel compression of the median nerves and Morton's metatarsalgia, J. Bone Surg., 31 560-71, 19^9 21. 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J.: Surgery in wrist drop, with reference to physical laws, Chirurg, 21: 422-3» June 1950 37* Thomas, D, F.: A method of arthrodesis of the wrist. Lancet, 1: 808- 9, Apr 29, 1950 38. Yergoz: Backward dislocation of the head of the ulna; technic of the Sauve-Kapandjy operation, Afrique fr. chir., —: **6-7, Jan-Mar 1950 39. Russell, T. B.; Intercarpal dislocations and fracture dislocations; a review of 59 cases, J. Bone Surg., 31 B: 524—31* Nov 1949 40. Dornan, A.: The result of treatment of Nienbock's disease, J. Bone Surg., 31 Bs 518-20, Nov 1949 41. James, J. I. P.: A case of rupture of flexor tendons secondary to Kienbock1a disease, J. Bone Surg., 31 B; 521-3* Nov 1949 42. Sohel, A., and Sohel, P.: Bilateral Kienbock disease, J. radiol. electr., 31: 13-4, 1950 43. Lippman, B. M., and McDermott, I. J.: Vitallium replacement of lunate in Kienhock's disease. Mil, Surgeon, 105: 482-4, Dec 1949 44. Annersten, S.: Some observations on lunate and perilunate disloca- tions, Upsala lak. foren. forh., 5**: 339-47, Dec 10, 1949 45* Waugh, E. L,, and Sullivan, R. F.: Anomalies of the carpus; with par- ticular reference to the bipartite scaphoid (navicular), J. Bone Surg., 32 A: 682-6, July 1950 46. Dwyer, F. C.: Excision of the carpal scaphoid for ununlted fracture, J. Bone Surg., 31 Br 572-7, Nov 1949 47, Hagen, R.s Isolated dislocation of the carpal scaphoid, Flln. Med., Wien., 5: 182-6, Apr 1950 48, Vaughan-Jackson, 0. J.; A case of recurrent subluxation of the carpal scaphoid, J. Bone Surg,, 31 Bs 532, Nov 19^9 49. Desse, G,, and Minet, J.: Osteolysis of the scaphoid hone of the car- pus; radiocarpal lesions in Thakery workers. Rev, rhumat., 17? 248— 51, May 1950 50, Caffaratti, E,; Congenital bilateral bipartite carpal scaphoid, Gior. batt. tmmun., 41; 430, Tan-Feb 1950 51. Avernier, L.; Treatment of pseudarthritis of the scaphoid, Mem. Acad, 46-7, Jan-Mar 1950 265 chir., Par., ?6: 117-23, Jan 11, 18, 19, 1950 52* Lasserre, C., Pauzat, D., and Derermes, R.: Osteoarthritis of the trapezio-metacarpal joint, J. Bone Surg., 31 Br 534-6, Wot 1949 53. Michele, A. A., Skinner, H. L., and Krueger, F. J.: Repair and sta- bilization of the first carpo-aetacarpal Joint, Am. J. Surg., 79* 348, Feh 1950 54. Oervis, W. H.: Excision of the trapezium for osteoarthritis of the trapezio-metacarpal joint, J. Bone Surg., 31 Bt 537-9, Nov 1949 55* Muller, 0. M..s Arthrodesis of the trapezio-metacarpal joint for oste- oarthritis, J. Bone Surg., 31 Bt 540-2, Nov 1949 56. G-iraud, M., and Vittori, M.s Case of divergent carpo-metacarpal dis- location; dorsal dislocation of the middle metacarpals and palmar dis- location of the fifth metacarpal, Lyon chir., 45: 601-4, July 1950 57. Flynn, J. E.: Acute suppurative tenosynovitis of the hand, N. England J. M., 242: 241-4, Peh 16, 1950 53. Bolton, H., Fowler, P. J., and Jepson, R. P.j Natural history and treatment of pulp space infection and osteomyelitis of the terminal phalanx, J. Bone Surg., 31 Bs 499-504, Nov 1949 59* Samuel, E. P.: Trans illumination of whitlows of the terminal phalanx. Lancet, Is 763-5, Apr 22, 1950 60. Oaron, W. M.; Tendon sutures, Laval mod., 15: 809-55, June 1950 61. Meyer, S. W.: A method of splinting the hand and fingers, N. York State J. M., 50; 1602, July 1, 1950 62. Jenkins, S. A.: Simple method of treating injuries of the fingers, Brit. M. J., 2; 252-3, July 29, 1950 63. Bernhard, E,; Injuries of the fingers with specific after effects upon the so-called middle joint. Praxis, 39: 426-7, May 18, 1950 64. Bunnell, S., and Howard, L. D., Jr.; Additional elastic hand splints, J, Bone Surg., 32 A; 226-8, Jan 1950 65. Tucker, W. E.; Traumatic conditions affecting the fingers, hand and wrist, Med. Press, Lond., 222: 494-6, Nov 23, 1949 66. Bunnell, 3.: Occupational therapy of hands, Am. J. Occup. Ther., 4t 145-53. Jul-Aug 1950 67* Kostler, 0. C.; Reconstruction of the deformed arthritic hand, Ann. Surg., 131: 218-24, Feh 1950 63. Buff, H. U.; Classification of injuries of the hand, and general as- pects of their treatment. Praxis, 39: 422-5, May 18, 1950 69, Liebolt, F, L.r The use of capsulectomy and arthroplasty for limita- tion of finger motion, Surg, Gyn. Ohst., 90: 103-?, Jan 1950 ?0. Rubin, L, R., Shapiro, R. N,, and Robertson, G, W,; Three fundamental principles of hand surgery. Am, J, Surg,, 80: 57-9# July 1950 ?1. Bruner, J. M.: Buttonhook retractor for hand surgery, J, Bone Surg., 32: 577-83. June 1950 72, Stenberg, G,: Full thickness grafts in finger tip injuries, Acta chir, scand,, 99? 1950 73. Gurdin, M., and Pangman, W, J.: The repair of surface defects of fing- ers by trans-digital flaps, Plastic & Reconstr, Surg,, 5: 368-71, Apr 1950 Macomber, W, B,; Relationship of superficial and deep reconstructive surgery of the hand. Plastic & Reconstr. Surg., 5: Feb 1950 75. Fuchs, F.; Dermatogenic contractures of the upper extremities, Ugeskr, laeger, 112: Mar 30, 1950 ?6. Clarkson, P., and Furlong, R,: Thumb reconstruction by transfer of big toe, Brit. M. J., 2: Dec 10, 19^9 ??♦ Rosenstein, P.: Substitution of fingers. Rev. brasil. med., 7: 376- 8, June 1950 78. Graham, W, C., Barrett, B, J,, and Cannon, B.r Elongation and digiti- sation of first metacarpal for restoration of function of hand. Arch. Surg., 61: 17-22, July 1950 79* Merle D’Aubigne, R,: Extensively flstulated white tumor of the elbow in a 65 year old man; good results after resection, Mem, Acad, chir,, Par., 76: 55-6, Jan 11,18,19, 1950 80, Hughes, N, C,, and Moore, F, T,: A preliminary report on the use of a local flap and peg bone graft for lengthening a short thumb, Brit. J. Plastic Surg,, 3* Apr 1950 61, Mithoefer, J.: Injuries limiting the mobility of the thumb. Am, J. Surg,, 79: Mar 1950 82. Howard, L, D,, Jr.: Contracture of the thumb web, J, Bone Surg,, 32A: 267-73, Apr 1950 83* Harris, H., and Joseph, J.: Variation in extension of the metacarpo- phalangeal and inter-phalangeal joint of the thumb, J, Bone Surg,, 31 Bs Nov 19^9 Bruner, J. M,? The use of dorsal skin flap for the coverage of palmar defects after aponeurectony for Dupuytren’s contracture. Plastic & Re- constr, Surg,, 4; 559-65, Nov 19^9 26 7 85* Thomson, G. R.: Treatment of Dupuytren's contracture with vitamin E, Brit. M. J., 2: 1382, Pec 17, 19^9 86. Gray, G. A., and DeTarnowsky, G. 0.; Dupuytren's contracture; report of two cases, U.S. Armed Forces M, J., 1: Jan 1950 6?. Ruamelhardt, S.r Dupuytren's contracture, Wien. med. Wschr., 100: 315-6, May 10, 1950 88. Wenzl, M.: Results of total palmar aponeurectomy in Dupuytren's con- tracture, Wien. klin. Wschr., 62 : 352-5, May 19, 1950 69. Paillot, J.: Dupuytren's disease, Rhumatologie, 99-102, May-Jone 1950 90. Oosthuizen, S. P.: Cyst-like changes in the small hones of the hand; the differential diagnosis, S. Afr. M, J., 23: 859* Oct 15, 19^9 91. Coventry, M. B., Woolner, L. B., and Anderson, M. E.: Hamartoma of the hand; report of case, Proc. Mayo Clin., 587-9, Eov 23, 19^9 92. Bosch, D, T., and Bernhard, W, G.: Lipoma of the pal®. Am. J. Clin. Path., 20: 262, Mar 1950 93. Prancon, P.: Hand in gout, Rhumatologie, —: 91-8, May-Jun 1950 Joly, L.: Hand in chronic inflammatory rheumatism, Rhumatologie, —•: 103-9, May-Jun 1950 95* Sorrel, E.: Attitude of the hand and fingers similar to the Tolkmann syndrome, following osteomyelitis of the forearm, Mem. Acad, chlr., Par., 76: Mar 22-9, 1950 96. Pelsenstein, P.: Symmetric contractures of the fingers as manifesta- tion of preureraic condition and its differentiation from other contrac- tures, Med. Klin., 696-8, June 2, 1950 97* Desse, H.; Epiphyseal defects of the phalanges. Rev. rhumat.. Par., 16: 526-8, Oct 19^9 98. Konar, N. R,, and Banerji, D.; Dystrophia myotonica, Calcutta M. J., 115-7, Apr 1950 99. Curtis, A. C., and Kirkman, I. V.: Diseases of the hands and nails. Oral Surg., 3: 288-355, Mar 1950 100. langenskiold. A.; Habitual locking of a metacarpo-phalangeal joint hy a collateral ligament, a rare cause of trigger finger, Acta chlr., 99: 73-6, Oct 31, 19*+9 CHAPTER XT’!!! AMPUTATIONS AND PROSTHESIS By August V. Spittier. Colonel, MC Brooke Army Hospital Pt. Sam Houston, Texas I* Indications and choice of procedure A. General B. Refrigeration C. Gangrene D. Choice E. Effects II. Techniques A. Shoulder girdle B. Hemipelvoctomy C. Cineplasty D. Krukenherg III. Complications A. Pain B. Scars C. Phantom limb IV. Construction and fitting A. Pitting B. Construction C. Suction sockets D. General V. After care A. Rehabilitation B. Nursing care C. Amputations in Malaya and Israeli There were 130 articles relating to amputations that appeared in the world literature in 1950 and ?8 were selected for review. Indications and Choice of Procedure In general consideration, EPSTEIN (l) reviews the history of a group of American leg amputees before 1900. Some of these amputees are forgotten but some became celebrities. The surgery was crude and most of them either used crutches or wore a peg leg. SCHUI/PZ (2) studied 100 consecutive amputees at Bellevue Hospital and found that two-thirds of the amputees were males, approximately 75 per cent 269 of lower extremity amputations were due to peripheral vascular disease, 50 per cent were unilateral above knee amputations and 25 per cent were unilat- eral below knee* Half of the patients were believed unsatisfactory for prosthetic fitting but many very elderly patients were trained in the satis- factory use of prostheses* The average age was 59 years (22 to 83)* WERTHEIMER et al (3) applied refrigeration to 60 cases which had arter- itis and gangrene of the extremities* In 23 cases anesthesia was sufficient for amputation, in 37 additional anesthesia was needed* Wound healing was normal* The refrigeration had a bacteriostatic effect and allowed the post- poning of the amputation until the patient’s general condition had improved* VOLPE (**) reports on refrigeration anesthesia in cases of amputa- tions of the limbs. He claims that three hours of refrigeration was suffi- cient. An excellent effect on the postoperative course and the healing of the wound was noted* SPRMGELL (5) also reports that refrigeration is an ideal anesthesia for amputation in gangrenous limbs* LARGE (6) using refrigeration studied wound healing and spread of in- fection in dogs. He found; (a) prolonged cooling delays wound healing, the degree of healing being roughly proportional to the duration of the cooling period, (b) the resistance of tissues to bacterial invasion decreases after cooling, (c) the Incidence of infection in wounds treatment by delayed pri- mary suture increases by refrigeration, and (d) nerve degeneration follows prolonged cooling of an extremity. SILBERT and HAIMOVICI (7) report on a series of 213 midleg amputations performed for gangrene. Primary closure was used in 6? cases. Of 50 patients with diabetic gangrene treated in this manner, healed by primary union and had a narrow area of gangrene along a small part of the suture line* In the nondiabetic group, primary healing was recorded in 11 out of 17 patients* In the entire series, rearaputatlon above the knee for gangrene of the stump was necessary in eight cases, and for contracture of the knee joint in two cases* The use of a tourniquet was thought to be responsible for three of these failures* The authors regard the following as indications for midleg amputation; (a) cases in which transmetatarsal amputation of one or all the toes has failed, with necrosis spreading toward the ankle, (b) cases with gangrene of several toes extending to or beyond the adjacent metatarsal re- gions and showing no tendency to demarcate, (c) cases with spreading gang- rene of the heel or above the ankle, and (d) cases with spreading gangrene of several toes associated with uncontrollable infection of the foot* There are three major contraindications to below the knee amputations; (a) exten- sive gangrene and infection of the leg with absence of the femoral pulse at the groin, (b) gangrene of the foot associated with flexion contraction of the knee Joint, and (c) recent thrombosis of the femoral artery* McLAUGHLIH and WIEDMAN (8) review the surgical management of infection ard gangrene in the diabetic extremity over a 1? year period, 1932-19^9• In those seen between there were 53 patients with infection or gang- rene of the lower extremities, an incidence of 6*6 per cent of diabetic ad- mission, In the past seven years additional patients were treated, re- presenting an Incidence of 6*8 per cent. The hospital mortality in the two 270 series of cases was reduced from 22*6 per cent to 16.2 per cent 'by: (a) ear- lier decision on a major amputation, and (b) antibiotic therapy, SMITH (9) reports the results of studies of 95 patients with amputa- tions for thrombo-aglitls obliterans and arteriosclerosis. The presence of the popliteal pulse before operation is an indication of success of the be- low knee stomp, but its absence does not exclude a below knee amputation. Tests for the vascularity of the part should be made both before and during amputation, WEINER (10) reports a case with menlngococcaemia and meningitis com- plicated by gangrene of the foot which later required amputation. 11 simil- ar cases have been previously reported, nine since The probable path- ogenesis of the condition is discussed with consideration given to such fac- tors as menlngococcaemia, shock, adrenal insufficiency, arterial spasm, and sludging of blood. SZABOLICS and BIKPALVI (ll) report 10 cases of arterial embolism as a cause for amputation. The obstruction was situated in the common iliac ar- tery ln#one, in the femoral artery in four, in the popliteal artery in three, in the axillary artery in one, and at the bifurcation of the aorta in one case. Conservative treatment was tried in three cases ( one femoral and two popliteal obstructions) but in all three the extremity had to be amputated, Embolectomies were performed on six patients, with five cures, CASACCI (12) describes a case of cutaneous ulcerated leprosy of the foot, treated by amputation. In discussing choice. SANTANELLI (13) advocates the Callander amputa- tion in vascular cases because of its simplicity, the fact that the flaps re- tain a good blood supply from the femoral artery, and that no muscles are cut through, (Bi: A knee disarticulation or a Gritti-Stokes amputation of- fers the same advantages with even bettor weight bearing possibilities,) ELDER (1*0 reports on the conservation of the foot following injury. As much tissue as is viable should be preserved, and the sacrifice of bone structure In order to obtain flap closure should not be countenanced. Nor is there any necessity to disarticulate the bases of metacarpals even though the heads and distal transverse ligaments may have been destroyed or severe- ly damaged, Equinus or varus deformities may be overcome or guarded against by appropriate operative measure to obviate tendon imbalance when the nor- mal insertion of a tendon has had to be sacrificed. A skilled prosthesis maker must be sought, (Ed! Amputations through the foot need good skin coverage. Many may better be converted to a Syme.) NABOR (15) abandoned end bearing stumps in cases of amputation of the leg, in favor of the more proximally bearing stump, RBGELE (16) believes that the present practice of covering an amputa- tion stump with muscle tissue should be abandoned and much muscle tissue should be removed at the time of operation. The stump (especially its end) should consist of skin, fascia and bone only. Effects are discussed by JENNY and ATJ5DERMAUR (1?) who report two cases 271 of spondylosis deformans of the lumbar spine due to the wearing of a pros- thesis that was too short or too long. In both instances the pathological changes in the spine were due to the abnormal static conditions and occurred after many years of use of the prosthesis. EELLEBRART et al (18) studied the effect of lower extremity amputation on the location of the center of gravity, postural alinement and stance sta- bility on 24 unselected subjects. Lower extremity amputation significantly elevates the height of the center of gravity. Prosthetic appliances compen- sate in part, but not in whole, for this displacement. Postural reallnement is necessary to relocate the center of gravity over the middle of the sup- porting base and should be considered a physiological adaptation essential to efficient use of the prosthesis. Techniques Under shoulder girdle. Ralph Cuming, a young British Raval Surgeon is reported by KBB7IL (19) to have performed the first interscapulothoraclc am- putation in 1808 on a young sailor injured in combat in the West Indies. It was performed without anesthesia and the patient survived the operation to be evacuated to England. MARGIN! (20) reports an Interscapulothoracic amputation in a case of fibrosarcoma of the humerus with good clinical result throe years after op- eration. MERENDIRO (21) describes a simple procedure which is applicable to pa- tients subjected to interscapulothoraclc amputation in whom a large surface of skin must be sacrificed. Use is made of the full thickness skin from the superior surface of the extremity to be amputated. The proximal portion of the skin remains attached and the flap is placed over the skin defect left by the amputation. BATZRER (22) reports an interscapulothoraclc amputation through a pos- terior approach for a sarcoma of the upper arm. It was necessary to reverse the usual anterior approach and approach the subclavian artery from behind, because of the extent of the tumor. The entire scapula together with the upper arm was turned forward, exposing the axilla with its nerve and vessel bundles from behind. GRIMES and BELL (23) discuss the use of the shoulder girdle amputation in the treatment of malignancies about the shoulder, and emphasize the res- ponsibility of the surgeon to propose the procedure rather than allow a maj- or lesion to progress in the face of inadequate surgery. They discuss the advantages of the posterior approach in mobilizing the scapula and in con- trolling the brachial plexus and the great vessels which are protected by the intact clavicle until the late stages of tne operation. In 10 cases there was no mortality from the operation. Eight articles on hemipelvectomy were published during the year. A literature review by SAIRT (24) revealed approximately 185 reported cases of hindquarter amputations. Mortality has dropped from 50 per cent to 15 per cent between 1940 and 1950 because of improved anesthesia, antibiotics and more adequate blood replacement. Tumors, without demonstrable metastases. 272 involving the Innominate hone itself are the primary indication for this type of surgery. A single case Including operative technique is described. A de- tailed account of patient care is included. It is erroneously stated that this amputation cannot he fitted with a prosthesis. YANCEY et al (25) give a list of the Indications for hemipelvectomy: (a) primary malignant osseous and periosteal tumors of the upper femur where the growth has extended to or through the hip Joint and for similar tumors of the innominate hones, (h) large primary malignant soft tissue tumors of the upper thigh (involving the hip Joint or extending through the obturator foramen), groin, buttock, pelvic parletes, and lilac region are best treated by this type of operation, (c) for palliative reasons, in Instances of foul. Infected, or painful malignancies of the upper thigh and buttock areas, (d) malignancies located below the knee but with extension up to the pelvic lym- phatics and no higher, (e) metastases from carcinoma of the penis or rectum in certain cases, and (f) in very rare Instances, for aneurysm of the femor- al artery, trauma and massive benign tumors of the pelvic bones or soft tis- sues. A case is reported. Long superior and medial (inferior) flaps have a better chance of survival than a long anterior flap. BOWERS (26) describes three cases of hlndquarter amputation and one interscapulothoracic amputation for malignant melanoma. local metastases had occurred in all. ARMOUR and LAWSON (2?) describe a case of hlndquarter amputation for Ewing*s tumor of the upper end of the femur. The patient is alive and well and walking with a prosthesis five years after the operation. ROBINSON (28) reports that hlndquarter amputation is facilitated by positioning the patient on his healthy side in a modified hip spica. Two operating teams perform the necessary surgery simultaneously, one handling the abdominal approach and the other the sacroiliac approach. The time of the operative procedure was shortened about 40 per cent. CORYN (29) reports a successful case of hindquarter amputation for osteomyelitis of the hip bone. BUCKNER et al (30) review a case report of a successful hemlpelvectomy for neurofibrosarcoma of the thigh. She was fitted and was able to wear a prosthesis but died eight months after surgery. A plea is made for early diagnosis, if successful treatment by radical surgery is to be accomplished. LE QUESNE (31) reports that the hlndquarter amputation is now possible with low operative mortality by careful preoperative preparation and adequate anesthesia. He uses induction with pentothal, maintenance with nitrous oxide, combined with unilateral spinal block, which enables a light plane of gener- al anesthesia. The incision circumscribes the ilium, which is detached by sections through the pubic symphysis and the posterior wing. The peritoneum and retroperitoneal organs are carefully displaced medially. An indwelling catheter is put in the bladder. Ho describes a special prostheses which en- ables those cases to walk fairly well. FINESILVER (32) reports the results of the clnenlastlc operation In a series of 17 cases of extensor and flexor forearm tunnels. (Ed: Forearm tunnels are not considered as efficient as a single ‘biceps tunnel in forearm amputees#) Ten amputees have constantly used their prosthesis at work and the routine pursuits of life over a period of from two to seven years# Of the seven remaining, four use their prosthesis part time, and three are con- sidered failures# LSBSCHE (33) gives the possibilities of the cineplastic operations for each site of amputation# KIESSEIBACE (3*0 in a kinetic analysis of Krukenberg1s amputation shows that the pronator teres, supinator, biceps brachii and brachioradialis mus- cles were the most effective muscles of supplying the power required for o- pening and closing pincers. In a fixed radius the pincers can also be worked by movements of the ulna, the triceps muscle acting as the opener and the brachialis as the muscle effecting the closure* KIESSELBACH (35) also pre- sents a thorough analysis of the muscle action in the Krukenberg arm based on clinical findings and on studies on the cadaver. It is pointed out that muscles change their direction of pull in regard to the axis of motion, de- pending upon the position of the elbow and the prongs. He compares the op- eration as done by Kreuz and Bauer. Kreuz believes that all muscle tissue between the prongs should be retained. Bauer states that the muscles on the ulnar side have no functional value and should therefore be removed. The author believes both methods to be too extreme, and points out that the mus- cle power which is available for closing of the prongs is less than for o- pening. He believes that some of the muscles should be brought over to the radial prong to reinforce the closing muscles. The rest of the muscles on the ulnar side may be resected. MOSER (36) reports that a muscle sense develops in cineplastic arm amputees, giving a sense of position of the fingers of the artificial hand# Phantom hand tends to coincide with the artificial hand, a phenomenon con- siderably enhancing the usefulness of the latter# PERESSON (37) reports on the results of the cases of double club or Krukenb erg-Puttl* s forcipate forearm. They were excellent in five, satisfactory in 19* mediocre in five, bad in tw9 and three cases were too recent to assess* In order to obtain a satisfactory prehensile function it is necessary: (a) to save at least two muscles of the forearm besides the supinator and pronator, (b) to lacerate the membrana interossea as proximal- ly as possible, (c) to lengthen the round pronator muscle, (d) to immobilize the stump, as soon as the operation has been carried out, in a position of supination with "fingers” separated, and (e) to start the functional reha- bilitation as soon as possible. Puttlfs stump with short "fingers" has proved more satisfactory than Krukenberg*s very long forked stump of the forearm* EALLIO (38) reports a case of a bilateral Erukenberg amputee who earns his living as a driver. He states that the result in this case emphasizes the Anglo Saxon conception of rehabilitation whereby the same surgeon from the beginning of the treatment has a personal contact with his patient, per- forms all the reconstructive operations and supervises his training until he is completely established in the employment most suitable for him. VAN NESS (39) reports that in most types of congenital defect of the 274 femur, there Is severe shortening of the thigh so that the ankle joint of the short limh often approximates the level of the knee joint of the normal side. The author has devised an approach to this problem. First, he cor- rects the pseudoarthrosis of the luxated hip. Next, he fuses the knee be- cause It is in a useless position just under the hip. During these two steps, every attempt is made to gain 180 degrees of rotation of the ankle. Should this rotation not be fully gained, a rotation osteotomy is performed. "By this procedure, the ankle joint can be utilized as an active knee joint. The foot serves as a partial bearing surface. Three cases with eight to ten year follow-up studies are reported. Complications In considering pain. MacDONALD (4o) in the after treatment of amputa- tion stumps reports that bandaging is one of the most important parts of af- ter treatment of all amputations. Before the stumps can "be fitted they must he fully shrunken and almost conical. It must he applied evenly and firmly with the idea of compressing the stump from its end upwards towards its base, and must be applied at least three times daily. Six inch bandages should be used for above knee stumps and four inch bandages for below knee or arm stamps. Hyperextension and adduction exercises should be started while the patient Is still in bed. Quadriceps exercises should be performed for below knee amputations. Before fitting, the wound should be healei without infec- tion, without pain nor edema and the stump must be shrunken to a reasonable conical shape. RUSSELL and SPALDING (4l) give a follow-up on report on the treatment of painful amputation stumps by percussion of neuromata and sensitive scars. Their original seven consecutive cases have continued to remain painfree with Intermittent percussion being necessary In a few cases. 33 additional cases have been treated with excellent results in 11 cases, good in eight, improved in five. These were all resistant cases. It is suggested that at time of amputation nerve endings should perhaps be left long and accessible for treatment rather than cut short. Sympathetic block or section Is still felt to be indicated for cold and diffusely tender stumps. SMIRNOVA (42) reviews 203 patients with 20? short BE stumps. None could wear their prostheses. Causes of failures were; painful scars - 65; ulcerations - 735 retained suture - 5; exanthemata and pyoderma - 5; osteo- myelitis - 19; osteophytes - 8; neuromata - IB; and neuritis - 11. Of these patients, 64 per cent had had a guillotine operation as the primary procedure and no skin traction had been used. She recommended a plastic closure of the stump using posterior rotated flaps as a method of treatment preparatory to prosthetic fitting. BAR (43) reports that recurrent contractures in two patients with am- putation through the upper thigh were due to the development of neuromas on the femoral nerve. Removal of the neuromas was followed hy permanent recov- ery. CIUFFINI (44) reports that ligature of the nerve stump with a nonab- sorbable thread is recommended for the prevention of amputation neuromas. This may he combined with the injection into the nerve of alcohol or of oth- er substances with a similar action. 275 NAYLOR (**5) reports a case of arteriovenous fistula complicating an amputation stump* The fistula probably either originated as the result of a mass ligation of the damaged femoral vein and artery or developed from dam- age to the arterial and venous walls at the time of the original Injury* In the matter of scars* BLOCK discusses plastic procedures for closing or revising stumps. McCOY (4?) discusses the: problem of reconstructive surgery in the am- putee to produce well-shaped scar-free stamps. He advocates full-thickness skin grafts from the opposite limb or abdomen rather than to extend the lim- its of the scar on the amputation stump. FRIEDLAND and COUTURE describe a simple, inexpensive brace devised for use in strengthening muscles of the lower extremity in disabled patients, which may be used to strengthen amputation stumps* The use of tetraethylammonlua chloride in treatment of •phantom limb is reported hy WINSTON A severe case of bilateral phantom limb pain fol- lowing above knee amputations for obliterative arteriosclerosis with intract- able pain is reviewed in detail* This 77 year old man required opiates re- peatedly for pain to which he became addicted* Sympathetic blocks failed to give relief* 13 months following the last amputation and 18 months following the first, I*V* tetraethylammoniura chloride was administered (Etamon) on four occasions, 2 cc* initially and 6 cc* three times over a nine day span with complete relief of pain* None months later a second series was given for some recurrence of pain following which complete relief has been obtained for over three years* Explanation is offered on the basis that the vasa ner- vorum may have been affected along with underlying pathology, i*c., obliter- ative arteriosclerosis producing neuro-ischemia* LERICHB (50) reports that the phantom pain Is the result of irritations, conscious or unconscious, traveling constantly in the sensory fibers In the same manner as in the intact member* The patient does not realize the ab- sence of a certain extremity* The nerve fibers examined will reveal the pre- sence of a neuroma or of the inflammatory changes on the basis of circula- tory pathology* Leriche injects these with novocain, dissects out the neu- roma with an electric knife and repeats Injections of 10 cc. of one per cent novocain for 15 days. The few patients treated by this method showed very encouraging results* KOLB (51) reports that definitive psychiatric treatment for intract- able pain in the phantom limb may be the preferred form of treatment for many patients. Phantom painful stumps are the most common following severe traumatic amputations where there is infection, scar and circulatory disorder, rather than in amputations resulting otherwise reports BEECK (52). War time ampu- tations seem to have more "phantom limb" than peace time amputations. LEG3R et al (53) report four cases in which small doses of intocostrln, 10 to 40 units daily, resulted after 10 to 15 days' treatment in complete alleviation of pains in the phantom limb. It is suggested that curare acts by inhibiting the actions of the autonomic nervous system* 276 H07AK and SIMK07IC present an analysis of 1636 amputees* Only seven per cent suffer no pain or discomfort* Four per cent have severe pain. Five per cent suffer from painful sensations of phantom lirah* JALAVISTO (55) analyzes a series of 173 arm amputations and studies adaptation in the phantom llmh phenomenon as influenced hy the age of ampu- tees* The processes thought to indicate adaptation were: disappearance of the phantom sensation, location of the phantom within the stump, and ”obsta- cle shunning” of the phantom when the stump was moved near a wall* These adaptation phenomena developed earlier after amputation and were more fre- quent (62 per cent ) In the young amputees that in the older group (38 per cent)* KALLIO (56) in an analysis of the permanency of results obtained hy sympathetic surgery in the treatment of phantom pain followed 68 cases, in- cluding eight stellectorales, lumbar sympathectomies, and 26 infiltrations. In the majority of cases (39) sympathetic surgery was found to have no ef- fect; in 29 cases the immediate results were good, but after one to four years, only six patients reported a complete cure. STEVISTSON (57) reports that the phenomenon of phantom limb* with or without pain, is still largely unexplained and is found to some degree in most amputees. Few of the many forms of operative treatment used for this condition have yielded success, although the method of treating the condition with percussion of the neuromata gives some promise and is currently being tested* In a group of 100 representative amputees investigated by the auth- or, the phantom limb sensation was present in cases, and pain accompanied the sensation in 1*K All of the true arm amputees except one experienced phantom limb sensations, and the high Incidence of this phenomenon among arm amputees is doubtlessly due to the rich nerve supply to the hand as compared to the foot* Construction and Fitting In fitting. ARZIMANOGLOU (58) realizing that a three Inch or three Inch below knee stomp slips oat of the artificial limb when the amputee kneels or ascends stairsv and that extension of the artificial limb is practically im- possible, offers a "slip” socket made to fit the short stump with a metal rod attached to the inferior surface of the leather socket which rests upon a coll spring. The firm, comfortable grip provided by the socket, and the steady upward pressure of the coll spring, prevent the stump from slipping out of the prosthesis. RAAGAARD (59) describes a pasteboard prosthesis for above knee ampu- tations which he has found useful in the rehabilitation of elderly patients* A pattern is provided, applicable to most cases, and by its use a prosthe- sis may be made by simply cutting, wetting, and fitting. KIAER (60) discusses the proper preoperative and postoperative treat- ment of amputation stumps of the lower extremities. The desirable amputation techniques for routine fitting of prosthesis are : (a) a conical painless stump, (b) a good myofascial layer at the end of the stump, (c) adequate cir- culation to prevent edema and necrosis, (d) hemostasis at surgery to prevent deep scar formation, (e) pressure bandaging postoperatively to control edema 277 and early exercising of the involved extremity to avoid contracture. He feels the cardboard prosthesis should he used only in an emergency. JOHANN (6l) reports that the disadvantages of the physiological knee joint in a prosthesis are (a) foot touches floor on swinging, (h) there is insufficient stability when extended, (c) it is complicated and expensive, and (d) aesthetically inferior to the uniaxial prosthesis. PEREY (62) reports on a walking school for leg amputees in Berlin, The school offers the limb maker and the therapist a practical laboratory to test new ideas in limb manufacture and use. Construction is discussed by SCHMITZ (63) who reports a new elastic substance "plastogen" which is used in sockets of prostheses. It can also be used in the finishing of suction prostheses whereby the suction is im- proved. MEISSNER (6*0 reports that reducing friction in the prosthesis to a minimum is necessary, so that the amputee achieves maximum safety and effi- ciency in walking and standing. The simple hinge joint is preferred. CANE (65) describes a peg leg which can be made by any medical officer wherever a carpenter is to be found. This artificial leg is only suitable for below knee amputations, weight-bearing being taken by the knee in a kneel- ing position. It is in fact a simplified form of the historical Chelsea Peg Leg used in Sigland since the Middle Ages, Total cost of completed leg is 13 shillings. About two days is required for patients to become accustomed to walking. AIDES (66) reports his experience with cases of above knee amputees fitted with suction socket prosthesis. The author concludes that the suction socket prosthesis can he successfully used In about 75 per cent of the above knee amputees if the stump is at least 10 Inches in length below the greater trochanter, is well formed and has good muscle tone. The best results with this prosthetic device were obtained with patients between the ages of 21 and 4-0. The majority of failures with the suction socket are due to poor fitting. The muscles of the stump hypertrophy and increase their physiolo- gic action with the wearing of a well fitting suction socket. THORNDIKE and EBEREAHT (6?) report that of a total of 606 patients fitted under the National Suction Socket Training Program, 73 per cent were then wearing the device routinely, 1** per cent were alternating between the suction socket and the conventional type limb and that 13 per cent were con- sidered failures. Under general. OUILICKSON and KOTTKE (68) give a lengthy discussion of the advantages and disadvantages of various amputations, prosthetic fit- tings, and methods of rehabilitation, (Ed: This article has many discre- pancies from what we now consider the most advanced ideas on the subject, particularly as regards the amputation sites in the arm). POTVIN and POTVIN (69) review advances in the technique of amputation and progress in the construction and fitting of prostheses. 278 After Care KESSLER (70) presents an integrated plan for rehabilitation of the am- putee. It is patterned after the programmes followed in restoring the 18,000 amputees of the American Forces of World War II* WERSSOVETZ and BAUM (71) give five major principles of rehabilitation of the amputee which they believe should be followed: (a) psychological and physical preparation of the patient, (b) adequate surgery and postoperative care, (c) preprosthetic treatment and training, (d) proper fitting and align- ment of prosthesis, (e) training in the use of the prosthetic device* Con- siderable stress is given to the psychological and physical preparation of the patient* MALINOVSKY (72) reports that vocational guidance of the disabled per- son differs little from that found necessary in the healthy individual but due to the distorted physical and mental frame of mind, guidance of the dis- abled person becomes complex* In order to evaluate the individuals abili- ties it became necessary to devise both vocational aptitude and psychologi- cal tests* The article reviews the results of vocational guidance in 112 amputees. In 66 per cent of the cases, there was a correlation between the recommendation and the placement, in l4 per cent there was a partial correl- ation, and in the remainder there was no correlation* GLOVER (73) discusses the problem concerning the need for performing amputations with complete rehabilitation in mind rather than merely extirpat- ing a diseased member and obtaining a closed stump* SIEMENS reports two cases of high double thigh amputations for severe flexion contracture of the lower extremities complicating spinal cord injuries with spastic paralysis* They were done to reduce the nursing care, to permit the individual to move about in bed with greater facility and thus minimize decubitus and urinary complications. M0SK0PP and SLOAN (75) describe the nurse*s responsibilities as begin- ning with the patient’s admission and continuing after the amputee is dis- charged. Proper nursing case can have a very important effect on the full rehabilitation of the amputee* CAMERON (76) discusses amputations in Malaya* Arterial diseases cause a large proportion of their amputations. Crude simple prostheses are used with little rehabilitation training. EEIPiN (77) and SPIRA (78) report on the social and medical rehabili- tation of amputees in Israeli, in a center established in Jaffa. . 279 BIBLIOGRAIHY 1, Epstein, S,: History of group of American leg amputee* before 1900: gome of them forgotten - some of them celebrated, Anglology, 1j 351- 68, Aug 1950 2, Schultz, W, M,: Rehabilitation of the lower extremity in a large gen- eral hospital, N. York State J. M,, 50: 2061-6, Sept 1, 1950 3* Wertheimer, P., Mansuy, L., and Girard-Madoux, P,: Refrigeration in vascular surgery, Lyon chlr,, 45: 327-9, Apr 1950 4, Volpe, L.: Refrigeration anesthesia, Acta Anaesth., Padova, 1: 490- 504, Hoy-Dec 1950 5* Sprengell, E,: Cold anesthesia and expectant therapy during applica- tion of cold, Eeltr, klin. Chir,, 181: 389-94, 1950 6, Large, A,: Physiologic amputation by tourniquet and refrigeration; treatment of infected gangrenous extremity. Arch. Surg,, 60: 683-90, Apr 1950 7, Gilbert, S,, and Haimovici, H.: Results of midleg amputations for gangrene In diabetics, J. Am, M, Ass,, 144: 454-8, Oct 7, 1950 8, McLaughlin, C. W,, Jr,, and Wiedman, J, G.; Infection and gangrene in diabetic extremity; critical review of surgical management over 17- year period, Nebraska M. J., 35: 316-9, Oct 1950 9, Smith, H. G.: Amputation above or below knee for primary peripheral vascular disease, J, Bone Surg,, 32 B? 392-5, Aug 1950 10, Weiner, H. A,: Gangrene of the extremities. Arch, Int. M,, 86; 877- 90, Dec 1950 11, Szabolcs, 2,, and Bikfalvi, A,; Treatment of arterial embolism, Magyar Sebeszet, 3: 203-11, 1950 12, Casacci, A,: Bone changes in leprosy, Clin, ortop,, 2; 37-52, 1950 13, Santanelll, L.: Callander amputation, Rev, mod. Rosario, 40: 72-80, 1950 14, Elder, H. M.: Conservation of the foot following injury. Am, J, Surg., 90: 718-21, Nov 1950 15, Haber, H. G, A.; Observations on lower limb amputation and prosthetic measurement, Ned, tschr, geneesk, 94: 1426-33, May 20, 1950 16, Regele, H, B,: A now method in leg amputation, Wien. mod. Wschr., 100: 274-5, Apr 22, 1950 17* Jenny, P,, and Aufdernaur, M,: Spondylitis deformans of the lumbar 280 spine in patients with amputation of the leg, Unfallned. Berufskr., 43: 303-10, 1950 18, Hellehrandt, P. A., Mueller, E, E., and Eubank, R. M.: Influence of lower extremity amputation on stance mechanics, J. Am. M, Ass,, 142: 1353-6, Apr 29, 1950 19, Keerll, J. J.: Ralph Cuming and the interscapulothoracic amputation in 1808, J. R. Nav. M. Serv., 36: 63-72, Apr 1950 20, Manclnl, 0,: Interscapulothoraclc amputation for fibrosarcoma of the scapula, Chir. org. movimento, 34: 304-10, 1950 21, Merendino, K. A,s Pull thickness pedicle flap graft from the amputated arm for large skin defects following interscapulothoraclc amputation. Arch. Surg,, 60: 376-8, Feb 1950 22, Batzner, K,: Interscapulothoraclc amputation with posterior approach. Arch kiln. Chir., 263: 377-82, 1950 23* Grimes, 0. P., and Bell, H. 0.: Shoulder girdle amputation, Surg. Gyn. Obst., 91: 201-9, Aug 1950 24. Saint, J. H,: The hindquarter (interlnnomlno-abdomlnal) amputation, Amer. J. Surg., 80r 142-60, Aug 1950 25* Yancey, A. G., Johnston, G. A., and Green, J. E., Jr.: Some surgical principles in hemlpelrectomy, J* Nat. M, Ass., 42: 210-13, July 1950 26. Bowers, R. ?.: Quart erect omy for malignant melanoma, Memphis Med. J., 25: 65-9, 1950 27• Armour, J. C., and Lawson, R. W.j The hindquarter amputation, Canad* M. Ass. J., 62: 371-4, Apr 1950 28. Robinson, R. A.: Interlnnoaino-abdoolnal (hindquarter) amputation, J. Bone Surg., 32 A: 446-8, Apr 1950 29* Coryn, J.: Osteomyelitis of hip as unusual indication for interllio- abdominal disarticulation; case, Acta chir. belg., 49: 249-52, Peb 1950 30. Buckner, H. T., McConrllle, B, E., and Callahan, J. J.r Hemipelvectomy, report of a case, Northwest Med,, 49: 874-5, Bee 1950 31. LeQuesne, L. P.: Hindquarter amputation, Overseas Postgrad, M. J., Lond., 4: 281-90, Jan 1950 32. Pinesllver, E, M.: Rehabilitation and the clneplastic amputation, Connecticut M. J., 14; 100-4, Peb 1950 33. Lebsche, M.: Loss of both hands, Arch. kiln. Chir., (Langenbeck*s), 265: 292-5, 1950 281 34. Siesselhach, A.: Analysis of motility of the Krukenberg arm in its different positions. Morph. Jahrhuch,, 407-33. 1950 35* Slesselbach, A.: Kinetic analysis of Krukenberg*s arm in its various postures, Anatomische Nachrlchten, Is 70-2, 1950 36. Moser, H.; Sauerbruch hand as sensory tool, Wien. kiln. Wschr., 62s 135-7. *eb 24, 1950 37. Peresson, A.s 7anghettlfs double cluh or Krukenberg-Puttl*s forcipate forearm, Clin, ortop., 2r 425-42, 1950 38* Kallio, K* E.: Demonstration of a bilateral Krukenberg amputee earning his living as a driver, Acta orthop. Scand., 19: 577-80, 1950 39- Van NesS C. P.s Rotation-plasty for congenital defects of the femur; making use of ankle of shortened limb to control knee joint of prosthe- sis, J. Bone Surg., 32 Bj 12-6, Peb 1950 40. MacDonald, A.r After-treatment of amputation stumps, N* Zealand M. J., 49: 273-84, June 1950 41* Russell, W. R,, and Spalding, J. M. K.t Treatment of painful amputa- tion stumps, Brit. M. J., 46?0: 68-73. July 8, 1950 42. Smirnova, L. A*: Plastic surgery of short leg stumps as a preparation for prostheses, Xhirurgla, Moskva, —s 58-63. Apr 1950 43* Bar, H«: The pathogenesis of flexion contracture in thigh amputation stumps, Zontralbl. Chir., 75? 227-30, 1950 44. Ciuffini, P*; Amputation neuroma and improvements in operative tech- nique for avoiding its formation; synthetic review and experimental contribution, Hass. med. sarda. Is 666-84, Sept-Dec 1950 45* Naylor, A.: Arteriovenous fistula complicating an amputation stump, Brit. M. J., 2: 928, Oct 21, 1950 46* Block, W*j Plastic procedures of the periphery of the stump, Chirurg., 21: 82-?, Peb 1950 4?. McCoy, P. J.: Special problems in reconstructive surgery in amputee; lower extremities. Am. J. Surg., 79? 295-301, Peb 1950 48. Priedland, V*, and Couture, M. M.; A progressive resistance exercise apparatus for physical rehabilitation of patients with amputations, fractures and paralyses of the lower extremity. Arch. Phys. M., 31: 401-5, June 1950 49. Winston, B. J,; The use of tetraethylammonlum chloride in treatment of phantom limb, Circulation, R. T., 1: 299-301, Peb 1950 50. Leriche, R.: Critical analysis of the pain mechanism in amputees, new therapeutic trends; prophylactic measures, J. chir. Par., 66: 5-21, 1950 282 51* Kolb, L. C.: Psychiatric aspects of treatment for intractable pain in phantom limb, Med, Clin. N . America, 34: 1029-41, July 1950 52. Beeck, M.j Phantom sensation and anatomical pattern; a study in the regression of the phantom limb, Hippokrates, 21: 320-2, June 30, 1950 53 • Leger, L., Lande, M., and Ballade, R.: Treatment with curare of phan- tom limb, Anesthesia, 7: 539-46, Nor 1950 54* Novak, P,t and Simkovic, I.: Painful amputation stump, Bratisl. lek. listy, 30: 422-9. Apr-May 1950 55* Jalavisto, E.: Adaptation in phantom limb phenomenon as influenced by age of amputees, J. Geront., 5s 339-42, Oct 1950 56. Kallio, K. E.: Permanency of the results obtained by sympathetic surg- ery in the treatment of phantom pain, Acta orthop. Scand., 19? 39k-?. 1950 57. Stevenson, G. H.: Amputations with special reference of phantom limb sensations, Edinburgh M. J., 57? 44-56, Jan 1950 58. Arzimanoglou, A.: Prosthesis attachment for short amputation stumps below the knee, J. Bone Surg., 32 A: 443, Apr 1950 59* Raagaard, 0. 7.: Pasteboard leg prosthesis for elderly patients, J. Geront., 5? 245-8, July 1950 60. Kiaer, S.: Cardboard prostheses, Ugeskr. laeger, U2r 960-1, July 6, 1950 61. Johann, K.: Physiological or single pin knee joint?, Med. Techn., Berl., 4: 78-30, Apr 1950 62. Perey, K.: Rehabilitation for leg amputees in Berlin, Mod. Techn., Berl., 171-3. Aug 1950 63« Schmltw, K. E.: Plastogen, a new prosthetic material, Med. Techn., Berl., 4: 77. 1950 64. Meissner, J. P.: Influence of frictional resistance upon the dymanlcs of the thigh prosthesis, Med. Techn., Berl., 4; 167-70, Aug 1950 65* Cane, L. H.: Peg leg. Bast Afr. M, J., 27? 119-26, Mar 1950 66. Aides, J. E.: Suction socket prosthesis for above knee amputee. Arch. Phys. M., 31: 709-20, Nor 1950 67. Thorndike, A., and Eberhart, H. D,: Suction socket prosthesis for above knee amputations, Am. J. Surg., 80; 727-31. Rov 15, 1950 68. Gullickson, G., and Kottke, P. J.: Rehabilitation of amputee, Journal Lancet, 70: 1-5. Jan 1950 69. Potrin, H., and Potrin, J.: Surgery and prosthesis for amputees; last decade, Bruxelles med., 30? 893-9, Apr 23, 1950 70. Kessler, H. H.: Amputees and artificial llmhs, J. Am. M. Ass., 142: 176-81, Jan 21, 1950 71. Werssowetz, 0, P,, and Baum, M. W.! Rehabilitation of the amputee. Mil Surgeon, 107: 1-19, July 1950 72. Malinovsky, L.: Vocational guidance with a group of amputees, Acta med. orient., 9? 97-10**, Mar-Apr 1950 73* Glover, J. R.: The major amputations. Am. J. Ruts., 50: 5****-50, Sept 1950 74. Siemens, W.: Bilateral amputation of legs in spinal cord injuries, Zentralhl. Chir., 75: 1317-20, 1950 75« Moskopp, M. E., and Sloan, J.; Nursing care for the amputee. Am. J. Nurs., 50: 550-5, Sept 1950 76. Cameron, J. A. P,; Artificial llmhs, M. J. Malaya, 5: 71-9* 1950 77* Reifen, D,: Social rehabilitation of amputees, Acta med. orient., 9: 79-96, Mar-Apr 1950 78. Spira, B.: The medical rehabilitation of war amputees, Acta med. ori- ent., 9: 69-78, Mar-Apr 1950 CHAPTER XIX m DEVICES, PROCEDURES, AND APPARATUS By Harold S* McBurney, Colonel, MC Murphy Army Hospital Waltham, Massachusetts I• X-ray techniques A. Planigraphy and differentiation techniques B. X-ray examination of the vertebrae C* Radiography of the hip II*. Devices A* X-ray aids B* Surgical aids C* Other devices III* Procedures A* Use of wires B* Diagnostic procedures C* Relief of pain D. Tissue repair IV* Apparatus A* Splints, casts, and supports B* Prostheses C. Aids for locomotion This chapter, containing 55 references, indicates a wide scope of pro- gress in the development of equipment and methods applicable to orthopedics* X-ray Techniques , Planigraphy and differentiation techniques are discussed by DJIAN (l). He writes, in an article entitled "Le Tomogramoe Vertebral," that planlgraph views of the vertebral column including A-P, lateral, and oblique reveal con- genital abnormalities in a much clearer fashion than common usage x-ray tech- niques* Differential diagnosis of osteoarthritis and tuberculous arthritis is made easier by this technique. The anatomical pathology of rheumatic les- ions clearly stands out* OIMO (2), in a brief article on roentgen-planigraphleal examination of the skeleton, points out that good diagnostic films on radiographic paper are made possible with planigraphy* Regular film is scarce in Spain, This is a useful method, especially in hip nailing, for demonstrating foreign bodies in the knee joint and for pathology of the teraporo-mandibular articu- lation* Microradiography of bone is described in an article by SISSOHS (3) who shows that all radio-opaque hone salts can he demonstrated, and thus, an accurate picture of hone architecture can he obtained* Cellular activity is correlated with structural arrangement, and the histology is linked with the findings of clinical radiography* X-rays are taken with fin© emulsion films on thin slabs of cut hone of about two millimeters thickness* Two new methods for x-ray examination of the vertebrae are suggested. A technio.ua for the roentgenographlc demonstration of the first cervical ver- tebra is described by WALTERS (*f) who states that visualization of this ver- tebra can be made through the foramen magnum with no bony super inrpo sit ion and no obscuration of bony detail. One lateral mass and the corresponding half of the posterior arch can be demonstrated in one exposure and may be duplicated on the opposite side* This method may be used in series study of port-traumatic cases in which a fixed degree of chronicity is present* It cannot be used in fresh cases or in those in which there is a marked limita- tion of the cervical spine. The upper portion of the patlent*s head is ele- vated 12 0 in the lateral position, and the tube is given a 23° tilt toward the feet. The central ray enters the skull five centimeters above and five centimeters behind the external auditory meatus. GUERREIRO (5), in discussing the lateral roentgenographlc examination of the thoracic spine, reports a most interesting technique for obtaining a full view of this portion without rib obscurance. With the patient in an orthostatic position with vertebral support, x-rays are taken of the spinal column in profile with the patient breathing deeply and slowly during the course of the exposure. 50 KV and 15 MA for 15 seconds at a focal distance of two meters is used. Complete disappearance of the ribs from the plat© occurs, and the spine is clearly outlined. This technique is excellent for detail of small compression fractures and arthritic developmental changes in the posterior portion of the body and in the articular processes. Profile radiography of the hip in vertical position is described by SEZE et al (6) who use the tube between the abducted legs and the ray directed up through the femoral neck with the plate parallel to the neck and held tan- gentally on the iliac crests or with the plate and tube reversed which pro- vides a method for obtaining good lateral projections of the head and neck of the femur. These views aid in the diagnosis of cases of congenital sub- luxations and other arthritic and dysplastic conditions of the hip joint. (7) reports in an interesting article, "Radiography of the Hip Joint, Lateral Projection — Extremity Extended," that two techniques with the patient supine are possible. The first is accomplished with the long edge of the 8 x 10 cassette resting vertically along the table top a- longside the coxyal region and the proximal short end pressed firmly into the patients side above the crest of the ilium. The distal end of the cas- sette is moved away from the lateral aspect of the thigh until the plan© of the film is perpendicular to the central ray. The tube is placed between the patient*s legs with the unaffected limb abducted and even resting on the tube tunnel. The localization point is one inch caudad to the iliac anter- ior superior spine and in the horizontal plane passing through the greater trochanter. In the second technique, the cassette is placed alongside the upper femoral region but held at a 65° angle, the junction of the upper two- thirds and lower one-third being opposite the greater trochanter. The cen- tral ray comes in at a 25° angle above the unaffected opposite limb. Both 286 techniojies give excellent views of the femoral head and neck region. This is a mast in hip nailing. Devices X-ray aids which further enhance the value of roentgenography in ortho- pedic surgery are presented. JACKSON BURROWS (8) of England describes a var- iable scale for measuring from radiographs in Smith-Petersen nailing which is used in hip nailing for arthrodesis and removes errors which may occur in reference to the magnification of the radiographic image. A graduated mea- sure in one-half and one centimeter markings on stout rubber is extended tel- escopically by means of a milled screw head. The x-ray shadow is equivalent to real centimeters in the body. The use of the scale relieves the surgeon of mental arithmetic. A simple adapter for mounting the head of an x-ray tube to a fracture table is described by LEONARD et al (9)» and this apparatus permits the ob- taining of diagnostic antero-posterlor and lateral roentgenograms quickly without displacement of the fragments or contamination of the wound in the closed railing of fractures of the femoral neck. The adapters permit the tube head to be moved in three directions, and they may be attached to eith- er type of fracture table. Tube head flexibility is much greater than when the head is fixed on a sacral rest. A large number of surgical aids are described. ROBSON (10) describes a table attachment for the electric saw which makes the use of the saw a safe procedure for one surgeon. The free saw is converted into a bench saw by means of a base plate and table of stainless steel. The blade rotates toward the operator and is exposed through a slot in the table. The motor is securely locked in place on the base plate. Markings of one-fourth inch on the plate assist in measuring graft widths. The instrument is easy to construct and has given complete satisfaction in its use* An adjustable bone-holding forceps, described by CHIRINOS (11), has a horizontal position which enables the operator to see the fracture site clearly and to apply screws and plate without obstruction. Butterfly nuts allow the superior arm of the apparatus to be adjusted for different thick- nesses of bone, and different sizes are available for various bones. The use of this instrument is first reported at McClosky General Hospital in Texas in 19^5* CANTOR (12) describes a new biopsy forceps which apparently has many merits. Most biopsy forceps have their Jaws arranged in alligator-like fashion, consequently lacking cutting force, and tearing of tissue becomes necessary in order to remove a specimen. In this new instrument, there are no jaws, and the cutting is done by an actual punch operation. By squeez- ing the handles of the instrument, the inner tube of the punch is simply moved forward, and, being of sharpened, hardened cutting steel, it cuts the tissue into the receiving cup cleanly and without tearing. For extremely hard tissue, cartilage, or bone, the inner cutting tube can be rotated by means of a milled handle at the control end of the instrument. MERVEHDING (13) describes a mallet to be employed in the performance of surgical procedures on bone and states that it is conical in shape, weighs two pounds, and is 8 long with a hexagonal handle. It has the follow- ing advantages: (a) it is heavy for easy wrist motion for a powerful "blow, (h) the operator can strike the chisel head and still keep his eye on the cutting edge which is not diverted hy the full transmitted force of blow, and (c) the problem of Injury to hand and glove as present with light smaller mallets is eliminated* BRUNER (1*0 describes a retractor for hand surgery which is modeled after the old-fashioned buttonhook, made of stainless steel, and provided with a suitable handle* It is used as a tendon extractor or retractor and, being smooth, causes little trauma in the finger, palm, or wrist* A self-retaining retractor for operations on long tones, described ty HIPPS (15), constantly exposes more than one-half of the circumference of a long tone in the field of operation. It does not need to te held in place, is easy to apply, needs no adjusting, and is easily constructed ty a machin- ist or trace maker. Two pieces of strong metal tuting are shaped with a central half-circle dip to go around the tone and are connected ty a solid extension on one arm to fit into the other arm of the hollow tute. VON LACKUM (16) describes the Universal stapler which has a long grasp- ing tool and wrench for a hexagonal nut which tightens the jaws to hold any size staple and permits staples to be introduced into wounds of considerable depth. The nut is easily loosened by the long wrench, and a groove on the end of the impactor is used against the transverse bar of the staple to drive it home* A simplified drill for the Bankart operation described by ALFRED (1?) is created by a right-angle burr used in the perforation of a maxillary an- trum. The burr is removed, and a steel drill point 5/6" long and 3/32 gauge is attached to the chain drive* Usual exposure is fully adequate for the proper placing of the drill point, and the angle of the drill is in perfect relation to the glenoid rim* Only a few turns of the drive shaft are neces- sary to drill through the rim* CLISY (18) describes a simple device to facilitate split-skin grafting* Subcutaneous Kirschner wires at each extremity of the donor skin site are held with traction stirrups, and a silk suture from the skin edge to the stirrup nicely delineates an area of skin to be removed with the Blair knife. The donor site is thus elevated and stretched evenly so that a uniform wide graft may be easily taken* Other devices depicted include a pin and stirrup for skeletal traction which PAUL (19) describes. He points out that loosening of a pin in bone may be caused by application of a wide stirrup that holds the pins rigidly. The apparatus described permits rotary motion of the stirrup about the pin but is narrow enough to prevent sideward thrust and motion. The narrowness of the stirrup is maintained by a transverse clip to the stirrup arms. This clip is fixed with a butterfly nut to prevent slipping or springing off* A modified goniometer with practical improvements is introduced by BERRESHEIM et al (20), This is a precision instrument with telescopic arms and a scale and is adaptable to all joint motions. Being of transpar- ent plastic material, it allows specific placement of the axis on landmarks. 288 and the weight is minimized. A thumb-screw feature at the base of the arms eliminates the necessity of excessive handling, while the well-defined mark- ings on the face of the instrument enable the operator to read the measure- ment with ease. GIBBMS (21) describes an easily constructed, inexpensive, rubber walk- ing heel which is nailed to a wooden block four inches long and the same width of the heel. 30 inches to inches of coat hanger wire is threaded through the center of the heel from side to side, extending upward to conform to the plaster boot. One or two rolls of four inch plaster hold the wooden block and wires to the sole and sides of the leg cast. The following advan- tages are pointed out: (a) it provides good balance, traction, and stability, (b) it is light and less prone to tear up bed linens, floors, and rugs, (c) it is less likely to slip on wet or smooth floors, (d) it is inexpensive and easy to construct from readily available materials, and (e) after use, the heel may be cut from the cast and used again. DUNLAP and KOODA (22) introduce a new contact bone plate. In this plate, there is 3/8 inch of movement taking place between two hooked plates which are contained within a stainless steel, tubular sleeve. The plates allow for three-hole fixation screw placements which are tightened against the bone cortex. There is no stress on the screw head or neck. Long plates may be used without fear of screw breakage. A simple, but rather ingenious, cast spreader is described by STEWART (23)* This spreader, which is both simple and effective, may be made from an automobile valve lifter. Two metal plates are brazed on the Inside of the Jaws. Good leverage is provided, and the ratchet attachment to the handles allows the blades to be held apart while underlying wadding is cut. Procedures The use of wires in orthopedic surgery is demonstrated by three authors. CHARNLBY of Manchester, England, describes a method of inserting the Smith-Petersen guide wire. A cannulated screw, with a tapering thread and controlled by a long-handled box-spanner which fits the hexagonal head of the screw, is introduced through a 3/16 inch hole into the cortex of the femur in the direction desired for the nail position. Through the cannulated screw the guide wire is introduced and x-ray films taken. If the guide wire is not in satisfactory position, the cannulated screw is reintroduced at a different angle, and another guide wire is placed. X-rays will reveal proper position- ing. The threaded screw may be used in about four cortical positions to serve as a guide to the wire. This method prevents the difficult positioning of the second guide wire as advocated by Watson-Jones. Nail length is deter- mined by measurement of the three inch threaded screw on the A-P x-ray film, and the factor of magnification is corrected by a simple graph chart. DEAN (25) writes an interesting paper discussing some surgical and technical aspects in the usage of wire sutures. Little or no tissue reaction is caused, and, in wound complications such as infections, hemorrhage, or ne- crosis, the wire sutures have a passive role and do not interfere with second- ary wound healing. Wire sutures alone cannot prevent dehiscence in wounds in patients with marked nutritional deficiencies. Ionization and electroly- 289 sis are not factors to be considered with the use of stainless steel wires. All wire sutures must he kept clean and free from rubber, oil, and resins which would contaminate the suture. Mixing of different alloys in wounds is not recommended. Sound judgment in the use and placement of sutures will allay the fear of wire migration to a vital structure. Skeletal suspension in the treatment of decuhlti is described hy CLARK (26) who states that skeletal suspension to avoid added pressure to areas of decubitus has been successfully accomplished by using Klrschner wires in the iliac crests and clavicles. The wires are connected to traction bows, and, by means of ropes, pulleys, and weights, the patient may be easily sus- pended for definite time periods during the day. With the pelvic suspension, his bed pan problem is made much easier. This method definitely helps the pro-operative phase for plastic closure of decubitl. Among the articles on diagnostic -procedures is an article by GOLDSTEIN and DEEISINGER (2?) describing a method for measuring the length of the bones of the lower extremity which is called spot orthoroentgenography and is a modification of Green’s technique. This method has been used since Standard x-ray equipment is needed plus a cassette x 36” and a brass cylinder 26” long and in diameter. Six rapid exposures are made over the ankle, knee, and hip joints, and the left wrist and hand are also taken on the same film for determination of bone age. target film distance is as accurate as greater distances and is more convenient. Individual ex- posures eliminate the distortion due to limb-length inequality, and, with a slight cost increase, this new equipment is easily added to existing standard x-ray apparatus. Sources of error are the positioning of joints and possi- ble shrinkage and expansion of the film. SHEA et al (28) write an interesting paper on electromyography in the diagnosis of nerve root compression syndrome. They report the use of this procedure, utilizing the monopolar needle electrode technique and a cathode ray oscilloscope, in 75 cases of compressive lesions of spinal nerve roots ( cervical, one thoracic, and 60 lumbosacral). Their results show this method to be accurate in 68 of the 75 cases. In contrast, myelograms are reported to be correct in 58 of 68 cases. Both methods are checked by oper- ative findings. The diagnosis of specific nerve root compression is made by finding of voltage characteristic of denervation fibrillation arising only from the skeletal muscles supplied by that particular nerve root. For relief of •pain. COOKRAB and BAKER (29) advocate, with certain re- servations, intravenous procaine therapy. They present an interesting paper on the subject and make an evaluation of the results of cases of various pain disorders. In patients with W? injections, there are only seven mildly toxic reactions which are uncomplicated and without morbidity or mor- tality. 250-30 milligrams of procaine HC1 in 300 cc. n/saline is given over a period of 20 minutes, and 90 to 120 milligrams of sodium phenobarbltal is given intramuscularly 20 to 30 minutes before the therapy. The authors con- clude that use of the drug is of clinical value in relieving pain. Best re- sults are seen in those patients with traumatic myositis, acute torticollis, or delayed serum sickness. In these, the relief of pain is immediate, pro- nounced, and of long duration. Results are not as satisfactory in other pain syairomes. 290 Useful procedures to be employed in tissue repair are presented by sev- eral authors. 1ATALHA (30) describes a new method of intraarticular arthro- desis by transposition of local cancellous bone by means of a tubular saw which removes the cancellous graft across a joint, e.g., hip or humerus. Graft is driven out of the saw, and the cartilage is removed and then rein- serted to proper depth. Operation is extra-articular, with little shock, and the method leads to firm, rapid fusion by using local cancellous bone. Local blood supply is not disturbed by severe open operation, and five cases, three hips and two shoulders, are reported with excellent results. TEMEFP (31) tells of method of osteosynthesis of the lumbar vertebrae. Bone grafting of the lumbar vertebrae used in non-infectlous diseases is done by means of a left side, lateral lumbar approach anterior to the trans- verse process. Notches are prepared in the vertebral bodies and are filled with an osteo-periosteal graft. The operative approach is easy, and the re- sults are positive. COLB (32) describes the immediate tendon repair with fascia lata trans- ference in a compound fracture treated with aureomycin. The tendon plastic procedure reported, done at primary operation in a contaminated compound fracture of an index finger, employs the use of aureomycin, 600 milligrams per day. The author reports that in two weeks immobilization was removed and primary healing had taken place. Motion was started in two and one half weeks. Thus, with coverage by antibiotics, a long delayed secondary repair is prevented, and early repair gives a better prognosis. MULLER (33) explains the construction of a palmar post. In gunshot wounds where most of the palm and all the fingers except the thumb have been shot away, it is advisable to construct an apposition post for the thumb to function against. Pinch and grasping are then possible, and the entire band may be quite functional. In the case described, abdominal tube flap pro- vides the skin, and the bony core is constructed from iliac bone. SHEEHAN and SWANKBR (3*0 report an interesting technique for the use of gelatihized bone for the repair of skeletal losses. Iliac bone is frag- mented and moistened with a solution of fibrin foam and topical thrombin be- fore it is ground in a conventional grinder from which it emerges as a brown, gelatinous substance. A cohesive mass is finally obtained by the addition of more fibrin foam and thrombin. This gelatinized bone is placed at the graft site by means of & spatula. Successful grafting is reported with this method is 20 cases for mandibular losses, malar flatness, depression of the nasal bridge, depressions of the orbital floor, and defects of the maxilla, frontal sinus, and cranium. This method can be applied to orthopedic surgery in any bone defect and may overcome the wandering effect of isolated chips. A now very popular incision, the posterior exposure of the hip joint is described in detail by GIBSON (35) of Winnipeg, Canada. This incision has been used by the author during the last 35 years. It is a modification of Kocher's posterior approach, and it has several advantages. As an ap- proach, it is rapid, almost bloodless, and attended by little shock. The power of the muscles is unimpaired as they are not detached from an exten- sive iliac origin. The gluteus maximus and tensor fascia lata, which are so important for stability of the hip, are not weakened, and the operation caus- es no instability. Dislocation of the femoral head from the acetabulum is 291 easily done by flexing the thigh and rotating it laterally. Uses for this incision would include reduction of posterior fracture dislocations of the hip joint, replacement of slipped upper femoral epiphysis, exposure of scla - tic nerve in the buttock, treatment of injuries to the gluteal arteries, ar- throdesis of the hip joint, and finally, cup arthroplasty or femoral head prosthetic replacement. The patient is placed on the sound side in the lat- eral position with kidney supports for positional maintenance. Apparatus In this section, most of the material contributed has to do with splints. casts, and supports. SCALES (36) of London, England, describes the use of polyethylene and resinated asbestos felt for splints and feels that this pro- c«dure is recommended. His reasons are that, excluding curing, production time is approximately one-quarter of that required for cellulose acetate or molded leather splints, which have to be steel reinforced, and the cost is about one-half. Other advantages claimed for the material are that it is light and durable, does not distort with use, is washable, is unaffected by sweat, urine, and feces, and is non-inflammable. It has been used for rigid splints such as pylons, spinal jackets, splcas, and long leg gutters. The self-retaining hoist, a new method of nursing in major orthopedic procedures, is described by HARRIS (37) of Australia. The self-retaining winding gear is a U. S. Navy bomb hoist or a similar mechanism Incorporated in any modern rotary clothes hoist. The self-retaining feature allows pa- tients to operate it themselves. Lifting of the patient Is effortless, and jerking is literally impossible, the velocity ratio of the hoist being l;hO. Venetian blind, webbing is used as straps on plaster casts, and these are connected by separate rings to a large, central, metal ring which is attached to the pulley rope. Ho strain or breaking of plaster casts is reported, and nursing care is reduced* LEVY (38) describes an appliance to induce toe flexion on bear- ing. The author uses a molded latex sole which is impressed to the foot with the toes in flexion. This elevated soft ridge at the metatarsal heads allows for active toe flexion when the patient Is walking. Plantar muscles are toned, and the transverse arch is elevated causing disappearance of cal- losities and symptoms of painful prolapse. The appliance has no value in cases where the toes are fixed or cannot be passively moved 10°. SCHULZ (39) states that celastic splints are durable, waterproof, light- weight, and adjustable. He says further that they may be used to advantage in an arthritic program. Pull details are given (with necessary precautions because of the inflammable nature of the solvent) for the construction of var- ious splints. The cost of construction is moderate. Reciprocal motion skiis for cerebral palsied children are described by KUHNEN (lK>) who claims that they teach a reciprocal pattern of walking, strengthening various muscle groups and teaching balance while in motion. The child is taught proper distribution of body weight, e.g., the balance of the right upper quadrant over left lower quadrant and the left upper quad- rant over the right lower quadrant. The child may also practice walking backwards. Ski walking Is the final step before walking unassisted. There is a good illustration of the apparatus in use with a detailed guide for con- 292 straction and use* SHORBB and McBRIDE (4l) describe a convex saddle frame which consists of two tubular steel pieces with convex curves reaching from the hor- izontal and being about 32" in length* These convex double bars are well padded, and their widths are adapted to the patient*a pelvis and shoulders by means of telescopic bars at each end which have adams set screws* The frame is used both in cervical and lumbar spinal operations, and abdominal pressure is eliminated in these positions* The chest and arms are free, and anesthesia is enhanced because of no direct anterior thoracic pressure* The convex spinal position gives much better lamlnal exposure. MOORE and EDMUNDS (42) describe a prone position frame which is another convex saddle frame made of 1" plumbing pipe. Two curved, vertical bars slide on an WE” frame by means of T-plpe connections which are held in cor- rect positions by set screws* The frame is adjustable for width only* High- est central point is 10", and the total width is IS-J**. The curved bars are covered with felt, 2" of sponge rubber, and, finally, a Eoroseal washable cover* Pressure bruises may occur over the maximal points of pressure on the iliac crest and side of the body. These are usually minimal, and there is no tissue slough. 80 successful cases are reported using the frame* A table extension to aid in application of a shoulder splca, described by MAG-ILL (43), is a tripod supporting a sponge rubber filled metal cup open on one side for the patient's head and a removable back support from the tri- pod to the table* It is a useful adjunct in work on reduction of fractures of the clavicle and in the application of plaster in forms of splcas, vests, and figures of eight. BOHSTEDT (44) describes an arm-traction apparatus which enables the bed patient to be elevated from a horizontal to an inclined or sitting posi- tion while the arm traction is kept in alignment at all times* Positional changes prevent hypostatic lung changes, especially in aged patients. The apparatus consists of a board clamped crosswise on the head end of the bed springs. To this are attached the standards for lateral and vertical trac- tion* An anchor counter and pull part may be applied to the opposite side of the board. BUNNELL and EOVARD (45) describe additional elastic hand splints which are used to exercise, mobilize, and change the position of stiffened joints in Injured hands, coaxing joints into position of function, or to complete the muscle balance in paralysis. Splints are used to change a hand from a position of a flexed wrist with fingers extended into a position of function. Single splints are used for single involved fingers. One set of splints draws out flexion contracture of the proximal finger joints seen in ischae- mic fibrosis of muscles of the hand. This is a reverse knuckle-bender. Good illustrations are provided. RUDOLFS (46) states that use of overshoe buckles in brace cuffs re- lieves the difficult problem of fixing laces or straps and buckles for pa- tients with hand disabilities as seen in poliomyelitis, cerebral palsy, and hemiplegia. The buckle is adjustable for loose or snug fit by means of its eyelets, and it represents a simple, time saving, and independent maneuver for the physically handicapped. 293 A bamboo staff for deltoid paralysis is described by SCOVILLE (4?) and is used in the place of the more cumbersome airplane splint for main- taining arm elevation. It is provided with a rubber crutch tip at one end and a cross bar and soft leather thong for wrist attachment at the uppermost end. The pole is pushed with the contralateral arm. The apparatus has good use indoors for patients with minor brachial plexus paralysis. VAN DYKE (48) describes a trochanteric splint which is a practical de- vice for preventing external rotation of the hip and lower extremities, es- pecially in polio. It is noted that, even with the feet against a foot- board, the metatarsal region will remain in place against the board while the legs rotate externally, producing varus and cavus foot deformities. Angled boards form a concavity which is filled with sponge rubber, and white felt webbing straps encircle the patient and hold the splints securely and comfortably. The felt is tapered off to prevent pressure sores. Practical adaptations for new types of prostheses are shown. ARZIMAK- CG-LOU (49) describes a prosthesis attachment for short amputation stumps be- low the knee. This is used to prevent a short stump (2W to 3” long) from slipping out of the artificial limb when the amputee kneels or ascends stairs and to obtain better extension of the artificial limb. A leather socket fits the short stump, and a metal rod runs from it to the foot section where a coll spring exerts upward pressure on the rod, thus giving the patient the feeling he is walking on his own foot. The apparatus does not have the dif- ficulties encountered in the ordinary prosthesis. The whole system is fit- ted into a conventional artificial limb. SHEAR and COMARR (50) describe a triceps substitute brace for quadri- plegics used in cases of spinal cord injury where the biceps is spared and the triceps knocked out. The brace restores muscle equilibrium and allows for sufficient function of the elbow Joint, permitting use of eating utensils, combs, brushes, etc. It offers resistive exercise for the biceps, acta as a cock-up splint for the hand, and furnishes an improved holder for eating de- vices. All contact points are covered with elk skin and padded with foam rubber. It is constructed of surgical steel and weighs only one and one- fifth pounds. The elbow Joint is a hinge type with an incorporated spring. Aide for locomotion are proposed by five authors. YAMSEON (51) de- scribes an aid to walking for patients with spastic hemiplegia which is pro- vided by elevating the sole and heel on the normal foot, facilitating the breaking of contact between the ground and the involved foot. This, in turn, diminishes the positive support reaction and stretch reflexes and allows for more adequate use of residual voluntary motion. Ambulation is improved by a decrease in the degree of shift of the center of gravity beyond the normal when weight is borne on the normal leg. Weight bearing is encouraged on the involved leg, and the step relationship in time and length of step between the normal leg and the involved log is improved. A brace for the correction of inversion tendency in clubfoot is des- cribed by HAUSER (52). It is designed to keep the feet in abduction and ex- ternal rotation while the child walks. A long metal rod is attached to the anterior part of the shoes, and the shorter rod is attached to the heels, both on the medial side. Rod length is determined by the size of the child and the length of steps desired. The front rod is usually 3” to 4“ longer than the heel rod# Hinges connected to the rods are attached to a flat met- al plate which is inserted between the layers of the sole and heel, and this arrangement allows motions in all directions# DEAVER (33)» in an interesting article on wheel chairs, stresses the point that the wheel chair must he suited to meet the needs of the disabled person. Comfort is important as well as the requirements of the area in which the chair is to be used and the obstacles that the area presents# All types of wheel chairs are discussed including descriptions and actions of such component parts as the wheels, brakes, back rest, arm rests, seat, foot boards and leg rest panels, trays, and toe-loops and heel straps# DEAVER in a second article, writes an interesting dissertation on what every physician should know about the teaching of crutch walking# Crutch walkers should learn a fast gait for open speed as in street crossing and a slow one for crowded places where balance must be kept. A variety of gaits should be taught to all crutch walkers, thus using different combina- tions of muscles and preventing fatigue from one common gait. Crutch gaits are really exercises strengthening many locomotion muscle groups# Crutch selection, measurements, muscular training, and various gaits are described# FRIEDLAITD and COOTTJHE (55) describe a progressive resistance exercise apparatus for physical rehabilitation of patients with amputations, fractures and paralysis of the lower extremity# The apparatus is basically a strong, double, upright knee cage with hinged, sliding, locking knee joints with long, leather laced cuffs for the thigh and leg. At the distal end, the up- rights are bent backward at a right angle and continue for 3'i* where the up- rights terminate in rings which permit the insertion of a metal rod to each end. Weights may be added to these rods, and exercises may be given by means of using the locked or unlocked apparatus# This apparatus may be used with amputations, fractures, and paralyses of the lower extremities, and in- creasing resistance is easily controlled by addition or subtraction of weight attachments as described. BIBLIOGRAPHY 1. Djian, A*: Vertebral planigraphy, -I, Radiol, electr., 30; 551* 19**9 2. (xuiterrea del Olmo; Roentgen-planigraphical examination of the skel- eton, Medlclna, Madr., 18; 199-212, Mar 1950 3. Sissons, H* A.; Microradiography of hone, Brit. J. Radiol., 23! 2-7• Jan 1950 Walters, B.j An additional technique for the roentgen demonstration of the first cervical vertebra, Am. J. Roentg., 63: May 1950 5. Ouerreiro, 0.: Lateral roentgenographlc examination of the thoracic spine, J. Bone Surg., 32 A; 192, Jan 1950 6. Seze, S., Jacqueline, P., and Djian, A.; Profile radiography of the hip in vertical position, Sem. hop.. Par., 26; 1357-60, Apr 18, 1950 7. 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Von Lackum, W,; Universal stapler, J. Bone Surg., 32 A; 701-2, July 1950 17. Alfred, K.; A simplified drill for the Bankart operation, J. Bone Surg., 32 A: Oct 1950 296 18. Clery, A, B,: Simple device to facilitate split-skin grafting, Brit. J. Plastic Surgery, 2: 290, Jan 1950 19* Paul, M. A.: Hew inventions; pin and stirrup for skeletal traction. Lancet, 1: 717» Apr 15, 1950 20. Berresheim, E., McKown, E. R., and Schnake, E.! Modified goniometer with practical improvements, Phys. Ther. Rev., N, Y., 29? 513* Tov 19^9 21. Gihhens, M. E,; An easily constructed, inexpensive rubber walking heel, Rocky Mountain M. J., 47: 26-8, Jan 1950 22. Dunlap, K., and Kooda, J. C.: A new contact hone plate. Mil, Surgeon, 107: 41-4, July 1950 23* Stewart, J. B.: A cast spreader, J, Bone Surg., 32 A; 445, Apr 1950 24. Charnley, J.: Method of inserting the Smith-Petersen guide wire, J. Bone Surg., 32 B: 271-2, May 1950 25* Dean, 0. 0,j Some surgical and technical aspects in the usage of wire sutures. South. Surgeon, 16: 250-61, Mar 1950 26. Clark, A. G. J Skeletal suspension in the treatment of decuhiti, Cal- ifornia M., 72: 447-9, June 1950 27. Goldstein, L. A., and Drelsinger, P.i A method for measuring the length of the hones of the lower extremity, J. Bone Surg., 32 A: 449- 52, Apr 1950 28. Shea, P, A., Woods, W, W,, and Werden D. H.j Electromyography in diag- nosis of nerve root compression syndrome. Arch. Neur. Psychiat. Chic., 64: 93-104, July 1950 29* Coonrad, R, V., and Baker, L. D,; Intravenous procaine therapy; an e- valuation of the results in 245 cases of various pain disorders. South. M. and S., 112: 181-5, June 1950 30. Batalha, E, de S, C.: New method in intra-articular arthrodesis hy transposition of local cancellous hone; a preliminary report, Am. J. Surg., 80: 85-92, July 1950 31. Teneff, S.; Original method of osteosynthesis of the lumhar vertebrae hy the lateral lumhar anproach, Rev. rhumat., Par., 17: 45-52, Eeh 1950 32. Cole, F, R.; Immediate tendon repair with fascia lata transference In a compound fracture treated with aureomycin, N. York State J. M,, 50: 2074, Sept 1, 1950 33. Muller, G, M,: Construction of a palmar post, Brit J. Plastic Surg., 3: 47-9, Apr 1950 297 34. Sheehan, J. E,, and Swanker, W. A.: Gelatinized hone for repair of skeletal losses, Brit. J, Plastic Surg., 2: 268-73, Jan 1950 35* Gihson, A,: Posterior exposure of the hip joint, J. Bone Surg., 32 B: 183-6, May 1950 36. Scales, J,: The use of polyethylene and resinated asbestos felt for splints, J, Bone Surg., 32 B: 60-5, Feb 1950 37* Harris, G.: The self-retaining hoist; a new method of nursing in maj- or orthopaedic procedures, Med, J. Australia, Is 523-32, Apr 22, 1950 38, Levy, B.: An appliance to induce toe flexion on weight hearing, J# Nat. Ass. Chiropod., 40: 24-33, June 1950 39* Schulz, B, P.; Celastic splints, Phys. Ther. Rev., N. Y., 29? 5^3-6* Bee 1949 40. Kuhnen, J. C.: Reciprocal motion skiis for cerebral palsied children, Phys. Ther, Rev. N. Y., 29: 517, Hov 1949 41. Shorhe, H. B., and McBride, E, D.j The convex saddle frame, J. Bone Surg., 32 A; 452-3. Apr 1950 42. Moore, 0, c,, and Edmunds, L. H,: Prone position frame. Surgery, 27: 276-9, Feb 1950 43. Maglll, H, K.: A table extension to aid in application of shoulder spica, J. Bone Surg., 32 A: 702-3, July 1950 44. Bohstedt, G.j Arnwtraction apparatus, J. Bone Surg., 32 Aj 438, Apr 1950 45* Bunnell, S., and Howard, L.: Additional elastic hand splints, J. Bone Surg., 32 A: 226-8, Jan 1950 46. Rudolph, H.; The use of overshoe buckles in braces, J. Bone Surg., 32 A; 953, Oct 1950 47* Scoville, W,; Bamboo staff for deltoid paralysis, J. Bone Surg., 32 A: 952, Oct 1950 48. Van Dyke, N. M.j The trochanteric splint; a practical device for pre- venting external rotation of the hip and lower extremities, Am. J. Nuts., 50: 268, May 1950 49. Arzlmanoglou, A.: A prosthesis attachment for short aranutatlon stumps below the knee, J. Bone Surg,, 32 A: 443, Apr 1950 50. Shear, H, R,, and Comarr, A. E.: A triceps substitute brace for quad- riplegics, Arch. Phys. M,, 31: 513-20, Aug 1950 51. Yamshon, L, J,: An aid to walking for patients with spastic hemiplegia. Arch. Phys. M., 31: 156-8, Mar 1950 298 52. Hauser, F. D. W.i A brace for the correction of inversion tendency in clubfoot, Phys. Ther. Rev., H. Y., 29: 507* Hov 19^9 53* Denver, G, G.: Wheel chairs, Phys. Then Rev., H. Y,, 29: 505-7* Nov 19^9 54. Denver, G. G,: What every physician should know about the teaching of crutch walking, J. Am. M, Ass., 104: 470-2, Feb 18, 1950 55* Friedland, P., and Couture, M. M.: A progressive resistance exercise apparatus for physical rehabilitation of patients with amputations, fractures and paralyses of the lower extremity. Arch. Phys. M,, 31: 401-5, June 1950 299 AUTHOR 'INDEX Abbot, A. F#, 78, 84 Abel, H. A., 213, 225 Abel, M. S., 178, 186 Abrahamson, M. L., 95, 111 Abrams, H. L., 151, 157 Adams, B. K., 95, 111 Adams, J, C., 175, 185 Adcock, J• B*, 40, 44 Adson, A. W., 142, 153 Aegerter, E, E., 28, 35 Ag Assiz, C. B, S., 87, 108 Aimes, A., 135, 159 Ajuriaguerra, J., 115 Akad, N., 203, 208 Ala Jouanine, T., 94, 111 Albert, A., 54, 67 Albrecht, K., 172, 183 Aides, J. H., 278, 283 Alexander, 0. M., 232, 241 Alfaro, A*, 3, 11 Alfaro, S., 5, 11 Alfred, K., 288, 296 Allende, G,, 59, 44 Allergee, &•, 237, 245 Alt, L. P., 65,71 Altemeier, W. A,, 65, 71 Amos, J, B., 55, 71 Anderson, K. J., 139 Anderson, M. E,, 55, 260, 268 Anglin, C., 83 Anglin, C. S., 84 Annersten, S., 255, 265 Antelo, J. N., 221, 226 Appel, B., 173, 185 Applebaum, E., 78, 84 Aranda de Rojas, M#, 39, 44 Archibald, R, M., 10, 15 Arden, G. P., 26, 34 Arkin, A. M., 27, 55, 158, 159, 160, 162 Armanet, B,, 39, 45 Armour, J# C., 275, 281 Armstrong, M, P., 74, 82 Arnaud, M,, 175, 184 Arnould, G., 101, 114 Aronovitch, M., 39, 45 Arons, P,, 19, 52 Arseni, C*, 237, 245 Arvay, N., 17, 51 Arzimanoglou, A,, 277, 283, 294, 298 Ascenzi, A,, 65, 70 Ashby, John B., Maj«, 37 Asherman, E. G., 232, 241 Ashworth, B#, 62, 'JO Aspin, J., 24, 35 Astley, C. E., 103, 115 Aub, J* C•, 7, 14 Audier, P. J*, 170, 182 Aufdermaur, M#, 271, 280 Austin, E,, 80, 85, 116 Avernier, L., 254, 265 Axhausen, G., 26, 34 Sachet, M., 166, 181 Baeder, D, H,, 54, 67 Baker, G. S., 100, 113 Baker, L. B,, 290, 297 Bakwin, H., 8 Balcher, M, R,, 56, 67 Balia, G. A., 49, 51 Ballantyne, B. A., 246, 264 Banerji, D., 261, 268 Bar, H., 275* 282 Barber, C. G., 132, 139 Bariety, M,, 24, 54 Barnes, A., 12 Barnett, H, E,, 88, 108 Baro, W. Z., 168, 181 Barrett, 258, 267 Barron, T, S., 201, 210 Barsant, A. W., 79, 84 Baruk, H., 103, 104, 115 Baskin, J. L#, 75, 83 Basom, W., 287, 296 Basset, G., 54, 67 Bastagli, B., 101, 114 Bastien, P., 203, 208 Batalha, E, S. C., 291, 297 Batzner, K., 272, 281 Bauer, G., 48, 51 Baum, M. W,, 279, 284 Bauman, C,, 167, 180 Baumann, J, A., 233, 241 Bazzi, T,, 101, 114 Bean, W. B., Ill Bearzy, H. J,, 203, 208 Beath, T., 214, 223 Becker, H., 100, 113 Becks, H., 65, 71 Beeck, M., 276, 285 Belenger, M., 157, 141 Belgrano, M., 159, 162 Bell, H. G., 272, 281 Belz, F., 175, 185 Benassi, E., 161, 163 Bender, H. R., 150, 156 Benes, V., 189, 197 Berg, C., 251, 264 Berne, C. J., 57, 68 Bernhard, E., 256, 266 Bernhard, W. G., 26l, 268 Berresheim, F., 288, 297 Bertrand, I., Ill Bertrand, L., 25, 34 Beyssac, P., 25, 55 Bianchi, F., 246, 265 Bickerstaff, E. R., 103, H5 Bikfalvi, A., 271, 280 Binde, H., 101 Binet, J., 155, 139 Binet, J. P., 155, 140 IttgfcH! 225 Bishop, R. E., 38, 43 Bisotti, P. L., 220, 226 Black, H., 96, 112 Blackstone, D. P., 166, 180 Blair, J. B., 132, 141 Blanche, D. W., 175, 185 Blankoff, B., 189, 197, 202, 208 Block, H. E., 165, 186 Block, W., 276, 282 Bluefield, C., Jr., 150, 156 Blum, H. L., J6, 85 Blunt, J. W., 54, 67 Bly, C. G., 56, 67 Bobroff, A., 218, 225 Bodman, F., 173, 184 Boecker, W., Bogen, E., 40, 44 Bohler, J., 135, 140, 252, 241 Bohning, F., 20, 52 Bohr, H., 119, 129 Bohstedt, G., 295, 298 Boissy, R., 230, 240 Bolgert, M., 29, 36 Bolton, H., 255, 266 Bonar, A. A., 204, 209 Bonnal, J., 115 Bonola, A., 156, 141 Booth, W. G., 217, 224 Borger, G., 171, 182 Bosch, D. T., 261, 268 Bostick, W. L., 144» 155 Bosworth, D. M., 59, 45, 121, 129 Bothelheiro, J., 192, 198 Boucher, C. A,, 216, 224 Boucher, R., 30, 56 Boudin, G*, 111 Boulvin, R., 247, 265 Bourel, M., 54, 67, 202, 208 Boutelle, W. F., 150 Bovissou, H., 40, 45 Bower, A. G., 77, 85, 85 Bowers, R. P., 275, 281 Boyd, J, D., 105, 116 Boyes, J, H., 251, 264 Boyes, J. W., 91, HO Bradford, C. H., 126, 151 Bradford, P. K., 175, 185 Bradlow, P. A,, 22, 32 Brady, T. A,, 58, 42 Brady, W. C., 86 Brailsford, J, F., 143, 155 Brandman, 0., 219, 225 Brandt, H., 40, 45 Brannon, E. W., 10, 15 Brauer, R. 0., 47, 51 Brault, P., 195, 199 Brav, E. A., 132-141 Breck, L., 287, 296 Brennan, J. J., 211-226 Bridgman, C. P., 286, 296 Brightman, I. J., 108 Brimfield, C. H., 166, 180 Brion, S., 35 Brixey, A. M., Jr., 2, 11 Brochier, A., 1, 11 Brochier, I. E. W., 158, 162 Brockbank, W., 190, 197 Brockway, A., 152, 139 Brooks, I). M., 249, 264 Bruesch, S. R., 75, 82 Bruner, J. M., 257, 259, 267,288,296 Brunsting, H. A., 247, 265 Brown, C.S., Lt. Col., 37 Brown, F. M., 75, 82 Brown, J. B., 256, 242, 245 Brown, J. E., 216, 224 Brown, S., 58, 68 Brownell, E. G., 150,156 Brua, R. S., 165, 186 Brucke, H., 157, 141 Brush, B. E., 4ft 51 Buchan, J. F., I46, 155 Buckless, M. G., 147, 155 Buckner, H. T,, 273, 281 Bucy, P. C., 145, 154 Buff, H. U., 257, 266 Buffat, J* D,, 174, 184 Buirge, R. E., 205, 208 Bulgarelli, R., 17, 31 Bunnell, S., 256, 266, 293, 298 Burgen, A, S. V., 59, 68 Burke, R. M., 2, 11 Burkhart, E. P., 2, 11 Burkle de la Camp, H., 156, 141 Burman, M,, 204, 209, 229, 239 Burns, H* A,, 40, 45 Burns, J, E., 47, 51 Burtt, E, J,, 108 Bushra, E,, 8, 14 Bustos, P* M., 170, 182 Butori, 190, 197 Buxton, S* J. D., 217, 224 Cacciapuoti, G, B., 97, 112 Caffaratti, E,, 254, 265 Caffey, J., 18, 32 Caldwell, G. A., 228, 239 Callahan, J. J., 273, 281 Calon, P, J. A., 95, 111 Cameron, J. A. P,, 279, 284 Campanario, M. de A., 169, 181 Campbell, D. A., 49, 51 Campbell, K. N., 219, 225 Camp, H. Burkle de la, 136, 141 Cane, L. H., 278, 283 Cannon, B., 258, 267 Cantor, A. J., 287, 296 Capecchi, W,, 206, 210 Carnsale, P, L., 203, 208 Caro, D. L., 143, 153 Caron, W, M., 256, 266 Carr, C. R., 86, 91, 109, 116 Carr, D, T,, 40, 44 Carter, A, B., 220, 226 Carter, E. K., 150, 156 Carter, S., 94, 111 Carttar, M. S., 50, 52 Casacci, A., 271, 280 Casiraghi, J, C., 179, 186 Caspe, S., 6l, 69 Cassebaum, W, H., 122, 130 Castillo-Odena, I., 204, 209, 251, 240 Catchpole, H. R., 56, 67 Cavalcanti, M», 251, 240 Cavallaro, V,, 192, 198 Cave, E, P., 205, 209 Cavina, C., 161, 165 Cawley, P. P., 39, 43 Certonciny, A*, 160, 163 Chambers, G, H., 187, 200 Chandler, P. A,, 145, 146,154,155 Chapchal, G., 136, 141 Chapman, R. J#, 173, 183 Charnley, J., 289, 297 Gharry, M. R., 191, 198 Gharry, R., 189, 197 Chavany, J. A,, 99, 115 Chaves, D, A., 192, 198 Chesney, M« 0., 220, 226 Cheynel, J., 193, 199 Chiapella, W. C., 83 Chiari, H,, 161, 163 Chigot, P., 109 Chigot, P. L., 169,181,193,198 Chinoy, J. J., 7, 14 Chirinos, J,, 287, 296 Chopin, B., 109 Christensen, E., 88, 108 Christie, H. K., 154, 139 Christopherson, W. M., 146, 154 Chusid, J. G., 103, 115 Ciuffini, P., 275, 282 Clagett, 0. T,, 90, 109 Clark, A. G., 290, 297 Clark, E. M., 82 Clarke, H. H., 59, 69 Clarkson, P,, 258, 267 Clery, A. B., 288, 297 Cleveland, M., 117,129,211,223 Clivio, I., 136, 141 Clybourne, H. E., 135, 140 Cohen, L., 104, 115 Cohn, C., 109 Colantuono, A., 59, 43 Cole, F. R., 291, 297 Coley, B. L., 143,149,153,156 Collard, A,, 51 Collazo-Gonzales, P.J., 72-85 Colling, K. G«, 100, 114 Collins, D. H., 145,154,212,225 Collins, V. P., 18, 32 Collis, E., 108 Comarr, A. £., 294, 298 Compere, C. L,, 27, 54 Compton, J. W., 150, 156 Comrie, E. Y., 248, 264 Conley, J. J., 149, 156 Constantini, H., 190,197,204,209 Goode, C. D., 206, 209 Cook, J. C,, 148, 156 Coonrad, R. W*, 290, 297 Cooper, G., Jr,, 149, 156 Copeland, M. M., 24, 34 Copello, P., 92, 110 Copello, 0,, 147, 155 Coppinger, W, R*, 57, 68 Corner, B., 19, 52 Cornil, L., 147, 155 Corradi, C., 120, 129 Corrigan, C., 5, 12 Coryn, J., 275, 281 Coste, P,, 24, 53, 54, 67, 167, 176, 180, 185, 206, 210, 255, 242 Courty, A,, 189, 197 Courty, L., 28, 56 Coury, C., 24, 54 Couture, M. M., 276, 282, 295, 299 Covalt, D, A,, 104, 115 Coventry, M. B,, 50, 52, 260, 268 Coville, 251, 240 Craigie, J., 143, 155 Cramer, H., 174, 184 Crawford, G.N.C., 68 Crawford, T*, 151, 157 Creese, R., 61, 69 Creyssel, J., 176, 185 Critchley, M., 91, HO Crosby, N, D#, 83 Curnen, E, C., 77, 84 Curth, H. 0., 17, 51 Curtis, A, C., 262, 268 Curtis, G. M,, 46, 51 Curtis, 0,, 12 Czickeli, H., 23, 55 Dal Lago, H., 170, 182 Danaraj, T. J,, 102, 114 Dancis, J., 109 Dandridge, S., 1 Dane, P. G,, 102, 114 D‘Angio, C., J., 151, 157 Dany, A., 62, 70 Dardill, 17, 51 Darris, C., 188, 196 D*Aublgne, M., 98, 115 Davidson, B,, 6l, 69 Davies, P. M., 29, 56 Davies, R., 21, 32 Dean, G, 0., 289, 297 Deaver, G. G., 295, 299 DeBakey, M. E., 49, 51 DeCamp, P, T., 49, 51 Decker, P,, 174, 184 DeGaetano, A., 20, 32 Dehlinger, J., 12 Dehne, E., 244» 268 DeJongh, S. E,, 8, 14 Delacroix, R#, 160, 163 Del Barre, P,, 54, 67 Delitala, F., 133, 159, 192, 198 deMarchin, P*, 17, 51 Demoulin, P,, 195, 199 Denisart, P., 99, 115 Dennis, E, W., 49, 51 dePaesi, F.J.A., 14 DePalma, A. F., 123, 130 DeSeze, 3., 23, 55 Desse, G., 195, 200, 254, 265 Desse, H,, 261, 268 DeTarnowsky, G. 0,, 260, 268 Dettloff, 38, 45 Deuoher, F,, 195, 200 DeVidas, J,, 91, 109 DeWulf, A., 7, 15, 158, 141 Diaz-Bordeu, E.,58, 42 Dick, G.W.A., 75, 82 Dickens, F., 59, 68 Diego-Caballero, A.D*, 229, 239 Dittrich, R.J., 170, 182 Djian, A., 285, 296 Doeden, D., 82 Dong, L., 82 Donohue, W, L,, 82 Doman, A,, 252, 265 Dreisinger, F,, 290, 297 Dressier, W,, 172, 183 Dripps, R. D., 65, 70 Dubois, J., 195, 199 Ducroquet, G.L., 17, 31 Dufour, P., 230, 240 Duncan, C*, 148, 156 Dunlap, K*,Col*, 55* 71, 289, 297 Dunn, A, W., 86, 116 Dupertuis, S. M*, 134, 140 DuPlay, J., 115 Durao, A., 135, 159 Durbin, F. C., 99, 115 Durieu, J., 187, 196 Dutra, F. R., 144, 155 Duvigneaud, D, G., 86 Dwyer, F. C., 255, 265 Dye, W. E., 40, 45 Earl, A, A., 75, 82 Earle, W. R., 145, 155 Easton, R. S., 39, 44 Eaton, J. M., 177, 185 Eaton, L, M., 109 Eberhart, H. D., 278, 283 Ebhardt, K., 58, 42 Echeverri, A, J,, 39, 44 Echlin, F,, 105, 16 Eckhoff, N. L. 1, 11 Eden, E., 55, 67 Edmondson, H,, 57, 68 Edmunds, L. H., 293, 298 Eggers, G.W.N., 88, 108 Ekbom, K.A., 96, 112 Elder, H. M., 271, 280 Elkin, D. C,, 49, 51 Elkins, E. C., 59, 69 Ellingsen, K,, 89, 108 Elst, E. van der, 137, 141 Emerson, G, A., 62, JO Emr, J., 3, 11 Ender, J., 138, 141 Engh, 0. A., 169, 181 England, L. C., 38, 42 Epstein, N,, 90, 109 Epstein, S., 269, 280 Erbelli, E., 58, 42 Erickson, P. T., 221, 226 Erlacher, P,, 5, 12 Ernest, E.C., jr#, 173, 183 Estridge, M. N., 25, 55 Eszenyi-Halasy, M,, 94, HI Etter, L. E., 64, 71 Euziere, J,, 92, 110 Evans, E. M., 245, 263 Evans, P. G*, 3, H Evans, H., 65, 71 Evans, J, A,, 105, 115 Ewing, M. R,, 98, 115 Ewing, P. L., 62, 70 Exner, G., 6, 13 Eyz Aguirro, C.-, 63, 7® Faber, H. K., 74, 82 Fabian, P,, 195, 198 Pagalde, A. E., 39, 44 Pahrni, W, H., 191, 198 Fairbank, H.A.T., 3, 12, 17, 22, 31 32, 146, 155 Falk, W., 29, 56 Pan, K, S., 6, 13 Parengo, 0., 179, 186 Fargo, V/. C#, 9, 15 Farina, R., 134, 140 Farrell, R, F,, 39, 45 Fatt, P., 62, 70 Fauconnier, H,, 23, 35 Fay, T., 87, 108 Feinstein, B., 62, "JO Pelber, R., 94, 111 Felder, D. A., 247, 263 Feldman, W. H., 40, 45 Felix, W., 159, 162 Pelsenstein, F*, 26l, 268 Fenner, H. A,, 165, 186 Ferguson, W* R., 57, 68 Ferguson, W. S#, 62, 'JO Pernandez-Rozas, P., 169, 18] Ferond, M., 230, 240 Ferre, R#, 235, 242 Perris, B. G«, Jr#, 84 Pinesilver, E. M., 273, 281 Fischer, K. A., 229, 239 Fischer, W., 38, 42 Fisher,R. H., 120,129 Fitzgerald, P. J,, 151, 157 Flesch-Thebesius, M,, 24, 35 Fletcher, W, B., 95, HI Plorian, M., 80, 84 Flynn, J. E., 249, 255,264, 266 Polk, B. P., 61, 69 Fontaine, R., 62, 70 Ford, L. T., 172, 183 Forestier, J#, 160, I63, 188, 196 Forrest, H. J., 6, 15 Forrester-Brown, M., 5, 12 Poti, M., 4, 12 Poultz, W. S., 86 Fowler, P. J., 255, 266 Pox, M* J., 79, 84 Fraisse, H,, 34 Prancillon, J., 168, 181 Prancillon, M. R,, 188, 196 Prancon, P«, 188, 196, 202, 208 261, 268 Frantz, C. H., 88, 108 Franulovic, P., 161, 163 Fraster, P. C., 110 Fredenhagen, H., 159, 162 Freedman, B,, 4, 12 Freedman, D., 93, 111 Freedman, D. A,, 112 Freeman, L,, 24, 34 Freund, J,, 75, 82 Priberg, S., 170, 182 Pridkin, V. I., 190, 197 Friedland, P., 276,282,295,299 Friedman,A, P,, 95, 111 Friedman,B., 159» 162 Friedmann, I., 148, 155 Fuchs, F#, 258, 267 Furlong, H., 258, 2d? Furmaier, A., 27, 55 Gainer, J. H., 40, 45 Galarcon, A. A., 2, 11 Galluccio, A.O, 229, 259 Galmiche, P*, 35 Gallagher, D.J.A., 96, 112 Gama, C., 175, 184 Gambier, R,, 204, 209 Garceau, G.J., 58, 42 Garcia-Calderon, J,, 233, 241 Gardner, E., 202,208,201 Garland, H.G., 103, 115 Gasking, C.T., 166, 180 Gauger, A.R.", 87, 108 Gaul, L.E., 217, 224 Gayral, B,, 3, 12 Gayral, L., 95, 111 Gdalevich, I.N., 119, 129 Geckeler, E.O., 128', 151 Gegany, A.J., 54, 67 Geiger, J, C,, 76, 83 Geisler, W.O., 79, 84 Gerard-Marchant, P,, 39, 44 Germaine, J*, 135, 140 Gersh, I*, 56, 67 Gersten, J.W,, 59, 68 Gervis, W.H., 255, 266 Geschickter, C.F., 57, 68 Ghersi, J.A., 235, 242 Ghormley, R.K., 206, 210, 27, 35 Gibbens, M.E., 289, 297 Gibson, A., 54, 189-197, 291,298 Giden, F.M., 87, 108 Giles, R.G., 145, 155 Ginsberg, M,, 59, 45 Giorgini, R,, 166, 180 Girard, P.F., 234, 242 Giraud, G., 169, 182 Giraud, M,, 255, 266 Girpwood, W., 222, 226 Gispert, C., 235, 242 Giuliani., K., 178, 186 Glander, R.,97, 112 Glas, W.W,, 201-210 Glaser, K., 7, 14 Glover, J.R., 279, 284 Glover, R.P., 109 Godlewaki, M., 23 Golan, H.P., 38, 42 Golden, P,B., 35 Goldie, H., 144, 153 Goldner, J.L,, 249, 264 Goldner, M.G., 57, 68 Goldstein, L.A,, 290, 297 Golseth, J.G., 116 Gonzal-Meneses, M.A., 3, li Gonzaga de Carvalho,J., 165-186 Gonzales, F,M., 58, 42 Good, M.G., 245, 263 Goodacre, C.L*, 40, 44 Goodbody, R,A,, 23, 55 Goodfellow, A.M., 82-85 Goodhill, V., 144, 154 Gordon, G#, 60, 69 Gordon, G.S., 62, 70 Gounaris, I.G., 230, 240 Graham, W.C., 258, 267 Gray, D.J., 201, 208 Gray, G.A., 260, 268 Grebe, A.A., 16 Greene, R,, ,17-, 51 Greenberg, M,, 75, 85 Griffiths, D.L. 190, 197 Grimes, M,, 61, 69 Grimes, O.F., 272, 281 Gollman, A., 145, 155 Grone Meyer, W,, 175, 183 Grosse-Brockhoff, F., 90, 109 Gruca, A., 160, 163, 41, 45 Guerin, R,, 251, 265 Guerreiro, G,, 286, 296 Gueuy P., 131 aruner, T., 92, 110 Gxueiich, W.W., 8 Guild, A.A., 93, 111 Guilleminet, M., 194, 199, 205, 209 Guiterrez, del Olmo, 285, 2$6 Gullickson, G., 278, 283 Gurdin, M., 257, 267 Guse, V., 230, 239 Gustilo, R.H., 173, 184 Guttman, L., 103, 115 Guyton, A.C., 79, 84 L,, 41, 45 Haas, S.L., 176, 185, 9, 15 Hackett, L.J,,Jr.f 146, 154 Hadders, H.N., 145, 154 Eaden, ff.D.Jr., 145, 154 Hadley, L.A., 171, 182 Hagen, R,, 254, 265 Hagenmuller, D., 99, 115 Haggart, G.E., 195, 200 Hahn,- P.F., 144, 155 Haimovici, H., 270, 280, 49, 52 Haines, R.S.,5, 15 Hakala, E.W., 142-155 Halborg, S.A., 119, 129 Halbstein, B.M., 191, 198 Hale, A.R., 8, 14, Hall, C.L., 251, 264 Hall, R.M., 6, 13 Hamby, W.B., 177, 185 Hammes, E.M. jr., 97, 112 Hammon, W,, 78, 83 Hancoz, N.M., 64, 71, 154, 159 Hansen, K., 25, 54 Hansen, P.B., 145, 154 Hansson, K.G., 80, 85 Harell. A,, 59, 89 Hargreaves, E.R., 78, 83 Hark, F.W., 214, 225 Harmon, P.H., 189,197, 228, 259 Harmon, P.H,, 121, 129, 155, 140 Haro, S., 218, 225 Harris, G., 292, 298 Harris, H., 259, 267 Harris, L.C., 65, 70 Harris, R.F., 214, 225 Harrold, C.C.,Jr., 149, 158 Hart, G.M., 7, 14 Hart, V.L., 5. 12 Hartog, B.J.C., 92, 110 Hartwich, S. 212, 223 Hathaway, E.Il , 217, 224 Hauck, G.J., 190, 197 Hauser, E.D.W., 294, 299 Haussler, G., 175, 185 Haven, H., 102, 114 Haverfield, W.T., 104, 115 Hawkins, C.F,, 7, 11 Hayes, W.M., 253, 241 Hays, A.T., 249, 264 Hazelrigg, T,, 102, 114 Heich, T.S., 54, 87 Heilburn, N., 173, 185 Hein, G.E,, 28, 35 Helket, A.J., 191, 198 Hellebrandt, F.A., 2/2, 281 Herabrow, C.H., 204, 209 Henderson, W.R., 154, 154 Hendry, A.M., 98, 115 Henry, M.O., 190 197 Hepburn, H.H., 177, 186 Hepp, 0,, 136, 141 Herbert, J.J., 135, 140, 177, 185 Herdner, E., 38, 42 Herrmann, H,, 61, 69 Hermann, J., 149, 158 Herschell, H., 167,180,215,224, 214,223 | Herscher, H., 229, 239 Herzmark, M.H., 214, 225 Hess, L, 98, 112 Heusghem, C., 31 Hiddlestone, H.J.H., 152 157 Hildreth, G., 8, 14 Hilkevitch, A,, 232, 241 Hill, A.V., 60, 69 Hill, R.M., 58, 68 Hilton, G., 147, 155 Hinchey, J.J., 175, 185 Kingston, J,, 20, 52 Hinshaw, H.C., 40, 44 Hipps, H.E., 288, 296,87,88,89,108 Hirsch, C., 170, 182 Hirsch, D.R., 89, 109 Hitchko, M.J,, 72 Hobbiger, F,, 61, 69 Hobby, G., 40, 44 Hochfeld, M., 58, 68 Hochfeld-011iviero, J,, 58, 68 Hodgkinson, R., 28, 35 Hoffmann-Kuhnt, H,, 214, 223 Holbourn, A.H.S., 60, 69 Holbrook, T.J., 66, 71 Holstein, A., 218, 225 Holt, H.P., 165-186 Homan, R., 57, 88 Horanyi, J., 195, 200 Hornberger, E.Z.jr., 78, 84 Horstmann, D.M., 77, 84 Horwitz, T., 133, 159 Hosford, J., 218, 225 Howard, L.D. jr., 258,266,259,267,293-296 Howard, R.P,, 25, 54 Howard, W.E. 39, 45 Howell, B.W., 249,264 Howells, G.H., 148, 155 Howell, T.H., 251, 241 Howes, E.L., 54, 67 Huard, P., 227, 239 Huberg, 38, 45 Huddleston, O.L., 85,106,116 Hudson, F.P., 99, 113 Hudson. O.C., 219, 225 Hughes, N.C., 259, 267 Hull, D., 244-268 Hultquist, G., 171, 182 Hurlburt, H.S., 74, 82 Hurst, A., 40, 45 Hutter, C.C., 148, 155 Hutter, C.G., 6, 13 Hutton, S.B., 49, 51 Huwyler, J., 39, 44, 156, 141 Hyatt, G.W., 155, 140 Hyland, H.H., 92, 110 Ibister, J., 254, 242 Ihlenfeldt, G.,27, 55 Inberg, K.R., 175, 184 Ingeirans, P*, 178, 186, 5, 13 Ironside, R#, 103, 115 Irving, J.T., 9, 15 Irwin, C.E., 249, 264 Iselin, M., 250, 264 Ivker, M., 151, 157 Ivsevich, I.S., 159, 162 Ivy, A.C., 58, 68 Jackson, A.E., 147, 155 Jackson*Burrows, H,, 287, 296 Jacobs, B.J,, 57, 68 Jacobs, J.E., 91, 109 Jacobi, H.P,, 62, JO Jacobson, W.E., 144, 154 Jaeger, F*, 173, 185 Jahss, M.H., 86 Jalavisto, E,, 277, 283 James, J.I.P., 154, 139,252,265 James, O.E.,jr., 148, 155 Jampol, H,, 250, 239 James, J•fe•, 9, 15 Jarcho, L.W,, 63, 70 Jaros, K,, 161, 163 Jaros, H., 212, 211, 225 Jeanopoulos, C.L., 204,209 Jefferson, N.C., 59, 45 Jenkins, S.A., 256, 266 Jenny, F., 271, 280 Jens, J,, 250, 240 Jensen, W.P., 106, 116 Jentzer, A,, 2, 11 Jepson, R,P., 255, 266 Jessop, W.J.E,, 9, 15 Johann, K,, 278, 285 Johnson, D.F., 145, 154 Johnson, H.F., 119, 129 Johnston, J.H,,jr,, 105, 116 Joldersma, R.D., 218, 225 Joly, L., 261, 268 Jones, E.M,, 59, 43 Jones, G.B., 216, 224 Jordan, J., 97, 112 Joseph, J., 259, 267 Judet, J., Judet, R,, 194» 199» 136,140 Rabat, E.A., 95, 112 Kaell, H.I., 146, 155 Kallio, K.E., 274, 282 Karlson, A.G., 40, 45 Karpinski, F.E, jr., 148, 156 Kastert, J., 252, 265 Katz, B., 60, 69-90-109 Katz, M., 90, 109 Kay, J.M., 49, 51 Kayser, C,, 62, 70 Keedy, C., 104, 115 Keevil, J.J., 2?2, 281 Keith, A*, 134, 139 Keizer, D.PR., 92, 110 Kelikian, H., 203, 208 Kellecher, W.H., 77, 84 Kelleher, J.J., 151 Kelley, V.C., 75, 82 Kemp, A., 175, 184 Kendair, E.C., 54, 67 Kendall, D,, 248, 264 Kemeis, J.P., 25, 34 Kessel, A.W.L., 228, 239 Kessel, J.P., 73, 82 Kessler, H.H., 279, 284 Ketelslegers, J,, 23, 33 Key, J*A., 172, 173, 183, 174, 184 Khoo, F.Y., 59, 45 Kiaer, S., 277, 283 Kiefer, E.J., 160, 163 Kierule, E., 17, 31 Kiesselbacfr, A,, 274, 282 Kilby, W.L., 20, 52 Kilfoyle, R.M., 126, 151 Kiloh, L.G., 98, 115 Kimberley, R.C., 48, 51 Kindred, R.G., 86 King, D., 189, 197 Kini, M.G., 195, 199 Kirkaldy-Willis, W.H*, 192, 198 Kirkman, L.W., 262, 268 Kirsch, J., 156, 140 Kissel, P., 101, 114, 10$, 116 Kite, J.H., 213, 223 Klein, M., 62, 70 Klein, R., 15 Kleinberg, S., 166, 180, 166, 180 167,181 Klima, M., 237, 243 Klopper, F«, 188, 196 Klovstadt, 0., 97, 112 Knauer, G.J,, 72 - 85 Kniedel, J.H*, 38, 45 Knowles, D.L., $2 Knud-Hansen, J.I.F., 86 - 116 Knutson, F,, 160, 162 Koch, W.E,,Jr,, 23, 35 Kodicek, E., 65, 67 Kohler, L.M., 21, 52 Kolb, L.C., 276, 283 Kole, W., 123, 150 Koletsky, S., 145, 155 Kooda, J.C., 189, 297 Koontz, A.R., 48, 51 Konar, N.R,, 261, 268 Kostler, 0.C,, 257, 266 Kottke, F.J., 278, 283 Kovacs, A., 171, 182 Kozhevnikov, P.V,, 17, 51 Kozla, M.M., 59, 45 Kraft, G.L., 147, 155 Krainin, P,, 151, 157 Kramer, W., 172, 183 Krauss, H., 28, 55 Kraus, S.D., 54, 67 Krayenbuhl, H., 177, 186 Kroll, P.W., 175, 184 Krueger, F.J., 128, 131 Kugelberg, E,, 59, 69, 175, 184 Kuhlendahl, H., 171, 182 Kuhnen, J.G., 292, 298 Kuhns, J.G,, 204, 209 Kulowski, J., 148, 156 Rung, Z., 100, 114 Kurt, H., 190, 198 Kutz, S.R., 39, 44 Kwalwasser, S., 159, 162 Kynaston, R.U.F., 26, 54 Lachapelle, A.P., 21, 52 Laduron, E,, 252, 241 Lafaury, A., 250, 264 Lafferty, J.O., 152, 157 Lagunova, I.G., 190, 197 Lake, N.C., 211, 225 Lam, C.R., 47, 51 Lance, 159, 162 Landa-Bacallo, M.A., 229, 239 Lande, 2, 11 Landry, B.B., 47, 51 Langenskiold,A., 262, 268 Langerbn, L., 161, 165 Langevin, R., 251, 240 Lapidus, P.W., 221, 226 Laporte, J., 40, 45 Laprade, C., 30, 36 Large, A., 270, 280 Largent, E.J., 144, 155 Larghero-Ybarz, P., 135, 241 Larkin, V.D.P., 22, 52 Lasserre, C., 23, 55, 254» 266 Lauge-Hansen, N., 127, 131 Laur, A,, 21, 32 Lautre, M.A., 105, 116 Lauwens, J,, 131 Lavedan, J*, 151, 157 Lawless, E.C., 147, 155 Lawson, R.W., 273> 281 Layton, L.L., 143» 155 Leatherman, K.D., 229, 239 Lebsche, M., 274, 281 Lecocq, E,A., 155, 159 Lecocq, J.P., 155» 159 Lecutia, T,, 148, 156 Legge, R.F., 46 Leger, L., 176, 283 Lehmann-Facius, H,, 175, 135 Lehner, A*, 177» 186 Lehoczky, T. von, 94, 111, 100 114 Leinwond, I,, 247, 263 Le Lievre, J., 218, 225 Lemaitre, 0., 28, 36 Lenert, T., 40, 44 Lenhard, R.E., 81, 85 Leonhard, M,, 287, 296 Lepine, E., 231, 240 Lequesne, L.P., 275, 281 Leriche, R., 24, 35» 276, 282 Leroux, R#, 25, 54 Lesem, A.M., 83 tester, C.W., 3f 12 Leventhal, G.S., 124, 150 Levin, I.M., 100, 113 Levine, M.A., 247, 263 Levin, M.L., 87, 108 Levinthal, L.H., 147, 155 Levernieux, J,, 159, 162 Levy, B., 292, 298 Lewin, H,, 39, 43 Lewin, P.M., 89, 109 Lewis, G,K., 47, 51 Lewis, K.M., 122, 130 Lewis, R.A., 10, 15 Lewis, R.B., 216, 224 Leyette, M, de la, 98, 109 Licht, S., 50, 52 Lichstein, H.C., 56, 67 Lichtenstein, B,W., 146, 154 Liebolt. F.L., 189-196, 257, 267 Liefooghe, J., 161, 163 Liesch, E., 160, 163 Lievre, J..A., 23, 33, 234, 242 Liljenthal, J.L.,jr.t 61, 63, 69, JO Limburg, C.C., 94, 111 Lindblom, K., 171, 182 Lino, L.B., 245, 265 Linton, R.L., 247, 263 Lipin, R.J., 39, 43 Lippman, E.M., 253, 265 Lipton, M.M,, 73, 82 Logan, W.P.D., J6, 83 Lohe, R., 207, 210 Longmore, T.A., 172, 183 Lopez-Vallejo, J,, 37, 42 Loreti, F,, 63, JO Loseff, H., 287, 296 Love, J.G., 160, 163 Lovell, W.W., 215, 223 Lowry, K.F., 46, 51 Lugiato, P., 132, 139 Lukanov, A.T., 41, 45 Lusskin, R., 86 Lux, H., 28, 36 Me Bride, E.D., 293, 298 Me Burney, H.S., Col., 38, 42,285,299 Me Candless, A., 113 Me Carroll, H.R., 157, 141 Me Comas, E., 41, 45, 217, 224 Me Conville, B.E., 205,209,275,281 Me Coy, F.J., 276, 282 Me Bermott, L.J., 253, 265 Me Donald, R., 91, 109 Me Dowell, I., 256, 243 Me Laughlin, C.W. jr., 2J0f 280 Me Lean, F.C., 50, 52 Me Murrin, J.A., 65, 71 Me Phee, H.R., 220, 226 Me Pherson, A.G., 23, 33 Maass Patino, J., 121, 129 Maccarty, C.S., 104, 115 Mac Conaill, M.A., 64, ?1 Mac Donald, D., 275, 282 Mac Dougall, J.T., 27, 34 Mac Gregor, M,, 21, 52 Mach, F., 133, 139 Macht, S.H., 39, 44 Mackay, R.P., 94, 111 Macomber, W.B., 257, 26? Magee, M.C., 83 Magill, H.K., 295, 298 Magi11, R.K,, 131 Magladery, J.W., 61, 69 Magnusson, R., 205, 209 Maier, E.R., 165 - 186 Makhlouf, A., 133* 139 Malaguzzi, V.C., 179* 186 Malinowsky, L., 279» 284 Mallows, H.R,, 4, 12 Maloney, J.V., jr., 84 Malzberg, B,, 87, 108 Mangini, G., 174, 184, 272-281 Mannino, R., 65, 71 Manzanilla, M.A.,jr., 105, 116 Marchal, G,, Marchand, J.C.A., 124, 130 Marconi, S., 203, 208 Marcovci, N., 237, 243 Marcozzi, G., 28, 35 Margoliash, E., 55, 67 Margules-Lavergne, M.P., 115 Mari Nacci, A.A., 116 Marino-Zuco, C., 39, 44 Marique, P., 169, 181 Maroger, B,, 97, 112 Marshall, C.S., 110 Martelli, F., 95, 111 Martens, E., 39, 43 Martin, B.C., 47, 51 Martin, E., 135, 140 Martin, G.M., 59, 68-69 Martin, H.E., 57, 68 Martin, J.F., 148, 156 Marx, C,, 62, JO Mascarenhas, G., 2, 11 Mason, H.L., 54, 67 Mason, M.L., 48, 51 Mathieson, D.R., 54, 67 Matusewicz, J., 28, 35 Mau, C., 103, 115 Maurer, H.J., 188, 196 Mautner, H,, 1, 4, 11, 12 Maxwell, G.S., 120, 129 Mayerhofer, E., 92, 110 Mayoral, A., 221, 226 Mayr, S., 176, 185 Mead, S,, 59, 69 Medbo, I.U., 187 - 200 Meier-Stauffer, G,, 215, 224 Meirowsky, A.M., 102, 114 Meissner, J.P., 278, 285 Meites, J., 55* 67 Melnick, J.L., 84 Mendlowitz, M., 215, 225 Menegaux, G,, 190 198 Merckelbach, F.M.L., 175* 185 Meredith, J.M., 146, 155 iterandino, K.A., 272, 281 Meriwether, T.W., 165-186 Merle, P., 99, 115, 171, 182 Merle-D'aubigne, R,, 189-197,195-194-199, 258, 267 Merritt, L.E., 217, 224 Metcalfe, D.C., 110 Meurer, H., 92, 110 Meyer, P.S., 219, 225 Meyer, S.W., 256, 266 Meyerding, H., 142, 155 Meyerding, H.W., 147, 155,287, 296 Meyer-Laack, H,, 105, 116 Michele, A.A., 128, 151, 254, 266 Michaelis, L.S., 251, 240 Michael, J., 88, 108 Michotte, L.J,, 206, 210 Milch, H., 157, 141,191,198,252,241 Miller, G.F., 95, 111 Miller, H.C., 1, 11 Miller, H.I., 95, 111 Miller, J.M., 59, 45 Miller, L.F,, 125, 150, 252, 241 Miller, R.J., 465-186 Milner, T,, 40, 45 Mills, C.A., 8, 14 Mills, S.P., 85 Milman, D.H., 8 Minet, J,, 254, 265 Minot, A.S., 61, 69 Mitbreit, I.M., 217, 224 Mitchell, J.R., 64, 71 Mitchesll-Heggs, G.B., 218, 225 Mithoefer, J., 259, 267 Moffatt, A.A., 207, 210 Monnier, J,, 40, 45 Monro, P.A.G., 105, 116 Montagne, M., 227, 259 Moore, D.C., 295, 298 Moore, P.T., 259, 267 Moorehead, S.F., 165-186 Moraes, F.D., 246, 265 Morgulis, S., 62, 70 Morrica, M,, 20, 52 Morrin, F.J., 178, 186 Horsier, D,, 255, 241 Morton, H. S,, 244» 265 Moser, H., 157, 141, 274, 282 Moskopp, M.E., 279, 284 Mueller, F., 59, 69 Muller, G.M., 255, 266, 291-197 Muller, K.L., 161, 165 Munaged, 104, 115 Munslow, R.A,, 175, 185 Murphy, J.W., 40, 44 Murphy, W., 25, 55 Murray, P.D.F,, 56, 67 Musgrove, J. E., 9, 15 Mushin, W.W., 65, 70 Mustard, W.T., 84 Naber, H.G.A., 2?1, 280 Nagel, L.C., 188, 196 Naidu, I.C., 195, 199 Nardell, S.G., 16, 51 Nash, C.C., 75, 185 Nassim, J.R., 151, 157 Nathanson, L*, 252, 241 Naylor, A., 276, 282 Nelson, M.M., 65, ?1 Nelson, T.F., 195, 200 Neuhauser, E.B.D., 4, 12 Neustadt, E., 204, 209 Newman, B.A., 18, 51 Newman, M.K., 104, 115 Nicholas, J.S., 61, 69 Nicholson, C., 166, 180 Niebauer, J.J*, Nissen, K.I., 4, 12 Nissl, R., 219, 226 Nixon, J.W., 144, 154 Noback, C.R., 9, 15 Nolan, J,0., 47, 51 Novak, P., 127, 285 Nowicki, V., 115 Nuessle, R.F.., 219, 225 Nutritional Reviews, 9, 15 Oberhill. H.R., 145, 154 Obrien, R.M,, 46, 51 Ochsner, A., 49, 51 O' Connell, J.E.A., 177, 186 O’Connell. J.G., 122, 150 O’Donnel. M.B., 108 Oehlecker, F., 58, 42 Oginsky, E.L., 40, 44 Oliver, B.R., 153, 159 Olivier, G., 217, 224 Olsen, A.K., 177, 185 O'Malley, A.G., 115 O'Meara, J.W., 113, 129 Oosthuizen, S.F., 260, 268 Ordoneau, P., 25, 33 Osborne, G.V,, 191, 198 Osmond-Clarke, H., 212, 225 Otermin-Aguirre, J.A*, 41, 45 Ottolenghi, C.E., 218, 225 Overbeek, V.J., v.d., 107, 116 Overton, L.M., 255, 242 Pack, G.T., 149, 156, 159, 162 Padovani, P., 168, 181 Paff, G.H., 65, 71 Pages, P,, 110 Paillas, J.E., 104, 115 Paillot, J., 155,140,260-268 Pais, C., 192, 198 Pait, C.R,, 73, 82 Paley, S.S., 101, 114 Palmer, H., 96, 112 Palmer, J.M., 59, 43 Palmer, K.W.N., 98, 113 Palumbo, L.T., 250, 240 Palun, J., 25, 35 Pangman, W.J., 257, 267 Paoletti, A., 40, 45 Pariente, R., 65, 71 Parkinson, J.L., 60, 69 Parmelee, A.H., 14 Parnes, I.H,, 150, 156 Parrish, F.T., 217, 224 Patino, M.J., 121, 129 Patterson, C.E., 173, 185 Patterson, R.L. jr., 217, 224 Paul, L., 168, 181 Paul, M.A., 288, 297 Pauwels, F., 27, 35 Pearson, C.M., 151, 157 Pease, C.H., 26, 34 Pecker, J., 96, 112 Pedersen, H.E,, 202, 208 Peikoff, S.S., 236, 245 Pendergrass, E.P., 152, 157 Peresson, A., 274, 282 Percy, K., 278, 285 Berkoff, G.T., 91, 110 Perles, L,, 188, 196 Perlstein, M.A., 88, 108 Perrot, A,, 169» 181 Perroy, A., 1?0, 182 Perry, J.F., jr., 144, 154 Perry, S.P., 145, 154 Petersen, I., 59, 69, 175, 184 Petr, R., 189, 197 Perusi, A., 160, 162 Peterson, L.T., 125, 124, 130 Pettko, E., 62, 70 Peyser, D,, 90, 109 Phalen, G.S., 166-180, 247, 264 Philip, W.M., 257, 243 Phillips, C.G., 60, 69, Phillips, C. W., 59, 43 Phillips, J.M., 152, 157 Piazza, A,, 21, 52 Picaud, A,, 168, 181 Pietra, A.D., 59, 43 Pike, M.N., 26, 54 Pilcher, C., 66, 71 Pipkin, G., 205, 209 Pirani, C.L., 56, 67 Pitney, W.R., 148, 156 Pitzen, P., 212, 225 Pique, J.A., 126, 151 Plattner, E.B., 14 Platou, £., 5, 13 Plotz, C.M., 54, 67 Polak, M., 145, 154 Polivka, D., 218, 225 Polley, E.P., 54, 67 Ponseti, I.V,, 159, 162 Poppen, J.L., 257, 243 Porot, J., 21, 52 Popovici, A., 57, 68 Pototschnig, H., 167, 180 Potter, T.A., 204, 209 Potvin, H,, 278, 284 Potvin, J., 278, 284 Poucel, J., 168, 181 Poulsen, T,, 58, 68 Power, M.H., 54, 67 Pratt, G.M., 49 Pratt, W.A., 218, 225 Pretl, K., 29, 56 Prevo, S.B., 149, 156 Price, E.E., 202, 208 Prick, G., 95, m Priessnitz, 0,, 170, 182 Prochazka, J,, 206, 210 Profitt, J.N., 145, 154 Pruvot, G., 206, 209 Provenzale, L,, 65, 71 Pudenz, R.H., 235, 242 Pujo, D.M., 27, 35 Purves, R.K., 238, 245 Pulvenaacher, I., 215, 224 Pulvertaft, R.G., 250, 264 Quirin, L.D., 250, 240 Raegaard, O.V,, 277, 283 Rackow, O.W,, 220, 226 Rader, D„, 75, 82 Rafel, S.S., 57, 68 Ralston, H.J., 62, 70 Raney, A.A,, 255, 242 Raney, R.B,, 255, 242 Ransohoff, N.S., 78-84, 159, 162 Rathcke, L., 189, 197 Ravault, ?., 26, 34 Ravault, P.P., 167, 180 Reavis, J.C., 28, 35 Redisch, W., 219, 225 Reeder, O.S., 117-131, 125, 130 Reeder, R.C., 79, 84 Regele, H.B., 271, 280 Regna, P., 40, 44 Reifen, D., 279, 284 Relly, W.A., 79, 84 Reinovsky, A., 57, 68 Reiss, E,, 173, 184 Remouchamps, L*, 97, 112 Ren, G,, de, 116 Rene, L», 230, 24O Raymond, J.C., 189, 196, 230,240, 232, 241-246-263 Reynolds, F.C., 155, 139 Reynolds, E.L., 65, 71 Rhodes, A.J., 74, 82 Ricard, A., 168, 181, 194, 199 234, 242, 176, 185 Rice, M.L., jr,, 102, 114 Richardson, J.L., 6, 15, 7, 13 Rider, J.A., 91, 109 Rieunau, G,, 124, 130 Ritchie, A.M., 82 Ritter, J.A., 90, 109 Rizzoli, H,V,, 255, 242 Robbins, W.J., 7, 14 Roberts, L.V., 23, 55 Roberts, M.A., 130 Robertson, R.L., 49» 51 Robichon, J.G., 187, 200 Robinson, D,, 229, 239 Robinson, F,, 115 Robinson, R.A., 275, 281 Robinsin, R.H.O.B., 146, 155 Robson, M., 287, 296 Roca, C.A., 221, 226 Roche, M.B., 120, 129, 166, 180 Rochet, P., 127, 131 Rodriguez, P.J., 40, 45 Roederer, C., 6, 13 Roederer, T.R., 160, 162 Roemer, F.J., 122, 130 Roger, H,, 96, 112 Rogers, H.G., 64, 70 Rogers, H.J., 64, 70 Rokta, M., 17, 31 Roldan, C.R., 59, 43 Roller, Z.V., 38, 42 Ronnen, J.R., 167, 180 Rook, A.J«, 17, 31 Rose, G.K., 160, 163 Rosenblatt, S,, 62, 70 Rosenstein, P., 258, 267 Rosin, I.E., 16 Rossiter, R.J., 100, 114 Rotes-Querol, J., 161, 163 Rouhier, 0,, 251, 264 R.c*, 72-85 Rountree, T., 248, 264 Rousseau , P., 22, 32 Rousseaux, P,, 116 Rowe, C.G., 166,180,194,199 Rowe, C.R., 205, 209 Rubenstein, B,, 109 Rubin, J.S., 229, 239 Rubin, L.R., 257, 267 Rubin, M,, 37, 68 Rucker, H,, 231, 240 Rudolph, H., 295, 298 Rummelhardt, S., 260, 268 Rushforth, A.F., 3, 12 Russell, L.W., 145, 154, 152, 157 Russell, T.B., 252, 265 Russell, W.R., 275, 282 Russo, P.E., 150, 156 Ruta, M.I., 246, 263 Ruther, H., 218, 225 Rutledge, E.K., 58, 68 Rylander, C.M., 211-226 Sachar, L., 119, 129 Sagastume, J.M,, 257, 245 Saha, A.X., 219, 226 Sahs, A.L., 95, 111 Saigh, R,, 78, 84 Saint, C.P.M., 254, 241 Saint, J.H., 272, 281 Saint-Marc, 188, 196 J,, 121, 129 Salembier, 220, 226 Salmon, 195, 194, 199 Salvaing, J.f 25, 34 Samitier, J., 40, 45 Samuel, E.P., 256, 266 Sangiovani, A., 38, 42 Santacroce, A., 18, 31 Santanelli, L,, 271, 280 Sanz, J.M., 161, 163 Sarasin, R,, 235, 241 Sarlin, L., 206, 210 Sarnoff, L.C., 84 Sarnoff, S.J., 80, 84 Sarroste, J., 157, 141 Sarpyener, M.A., 203, 208 Satanowsky, S,, 203, 20$ Saxl, A., 187, 196 Scales, J., 292, 298 G», 204, 209 Schacter, M., 93, 96, 111, 112 Schaffee, W., 161, 165 Schajowicz, F., 145, 154 Schalle, H,, 37, 42 Schapiro, S,, 195, 200 Schaubel, H.J., 167, 181 Scheibert, C.D., 102, 114 Scheldt, R., 124, 130 Scheller, H., 176, 185 Schenken, J.R., 146, 155 Schemer, J,, 111 Schilling, E.L., 145, 153 Schlenk, F., 62, 70 Schmitz, K.E., 278, 283 Schneeberg, M.G., 23, 53 Scholder, J.C., 6, 13 Scholer, G,, 173, 184 Schrey, E.L., 206, 210 Schuler, F.B., 195, 200 Schultz, A.H., 195, 199 Schultz, E.C., 235, 242 Schultz, W.M., 269, 280 Schulz, B.F., 292, 298 Schumacher, G.A., 94, 111 Schwartz, A.A,, 121, 129 Schwensen, C,, 99, 113 Sciarra, D., 94, 111 Scobey, R„R,, 72, 82 Scott, R.B., 2, 11 Scott, W., 6, 15 Scougall, S.H#, 167, 181 Scoville, W., 294, 298 Scuderi, C., 206, 210 Secher, 0,, 58, 68 Seddon, H.J., 245, 263 Segal, S,, 12 Seghini, G,, 38, 42 Seidenstein, H,, 221-226, 252, 265 seigman, E.L., 20, 32 Seifter, J., 54, 65, 67, 71 Sellers, D., 244-268 Sellers, K.C*, 55, 67 Semraes, R.E., 235, 242 Sepich, M.J., 237, 245 Seree, 58, 43 Seymour, B.E., 40, 44 Seize, S.D., 171-172, 182-183, 187-196, 250,239,240, 286-296 Seze,S., de, 159, 162 Shaw, E.W., 84 Shea, P.A., 290, 297 Shear, H.R., 294, 298 Sheehan, P.T., 236, 242 Sheehan, J.E., 291, 298 Shelden, C.H., 235, 242 Shelton, E., 143, 153 Shepard, R.H., 8, 14 Sherman, R.S., 151, 157 Sherman, M«S,, 25, 34 Shimada, P., 82 Shimonek, S.W., 27, 35 Shinners, 177, 185 Shell, D.A., 14 Shorbe, H.B., 295, 298 Shulman, S., 190, 197 Sicard, A*, 133,135,159,140,166,180, Siffert, R.S., 27, 35 Siffre, J., 135, 140 Siegel, M,, 83 Siehl, B., 173, 185 Siemens, W., 279, 284 Silberberg, M., 8, 14 Silberberg, R., 8, 14 Silbert, S., 270, 280 Siler, V.E., 249, 264 Sillevis, S.W.G., 257, 243 Silverberg, R.J., 82 silverthorne, N., 75, 83 Simeone, F.A., 247, 263 Simkovic, I,, 277, 283 Simpson, T.R., 221, 226 Simon, N., 159, 160, 162 Sinigaglia, D., 28, 36 Sinnige, J.L.M,, 92, 110 Siska, K., 192, 198 Sissons, H.A,, 285, 296 Sitterley, J.L., 58, 42 Skarenborg, H,, 204, 209 Skrygin, V.P., 159, 162 Sloan, J., 279, 284 Slobodkin, M., 232, 241 Slocumb, C.H*, 54, 67 Smelin, A., 151, 157 Smirnova, L.A., 275, 282 Smith, A.])., 39, 43 Smith, F.M., 121, 129 Smith, H., 125, 130 Smith, H.G., 271, 280 Smith, L,A., 38, 43 Smith, O.E., 2, 11 Smith, P.H., 40, 44 Smith, R.G., 49, 51 Sobel, A,, 253, 265 Sobel, P., 255, 265 Sohier, 231, 240 Sohier, P.T., 99, 113 Solnitzky, 0., 98, 113 Somerville-Large, C,, 219, 225 Sonnenschein, R.R., 58, 68 Sonnenschein, V., 106, 116 Sorge, W*, 38, 42 Sorrel, E., 261, 268 Sooza-Biaz, A.G., 39, 45 Soule, A.B,,jr., 102, 114 Soule, E.H., 85 Southcott, R.V., 76, 83 Spalding, , 275, 282 gpencer, H.A.*, 146, 155 Spinola, N., 120, 129 Spira, E., 279, 284 Spiroff, B.E.N., 58, 68 Spittler, A.W., 10, 15, 269, 284 Spotorno, A,, 7, 13 Sprague, R.G., 54, 67 Spray, P.E., 206, 210 Sprengel, H., 276, 280 Sperling, R.G., 98, 112 Stamm, T.T., 215, 225 Stapelmohr, S,, von, 232, 241 States, J.B., 165, 186 Stearns, G., 55, 87 Stecklemacher, S.A., 101, 114 Steinberg, S.H., 22, 32 Steinberg, G,, 257, 267 Stenger, E., 230, 239 Stenhomse, N.S., 83 Stephens, F.E., 17, 51 Stevenson, C.A., 86, 116 Stevenson, G.H., 277, 283 Stevenson, T.W., 144, 154 Stewart, J.E., 289, 297 Stewart, M.J., 148, 155 Stiff, B.W.S., 102, 114 Stimson, P.M., 78, 84 Stinchfield, F.E., 192, 198 Stol, J., 6, 13 Stone, M.A., 157, 141 Stone, S,, 78, 84 Stonehill, T,, 236, 242 Storck, H., 5, 15 Stortebecker, T.P., 89, 109 Stovall, S.L., 119, 129 Stow, R.M., 40, 44 Stracker, 0., 137, 141 Strang, C,, 29, 56 Strassburger, P,, 222, 226 Straub, F.B., 62, 70 Straub, L.R., 84 Strayer, L.M.,jr,, 127, 131 Street, B.M., 125, 130 Strieker, P., 28, 36 Strong, J.M., 167, 181 Strong, W.R,, 86 Stuart, F.W., 160, 165 Stucke, K., 219, 225 Stuck, W.G,, 190, 198 Sturzenegger, H,, 166, 180 Suarez-Pupo, J,, 147, 155 Sullivan, R.F., 253, 265 Sulon, E,, 65, 71 Sutherland, J.M., 95, 111 Sutherland, K., 56, 67 Swanker, W.A., 291, 298 Swynghedaus, 220, 226 Szabolcz, Z., 271, 280 Sztaba, R., 37, 42 Talbot, S., 99, 115 Talbot, S.A., 63, 70 Tamalet, J,, 170, 182 Tansella, G,, 91, 110 Tanz, S.S., 165, 180 Tapie, J., 40, 45 Tarrant, R.M., 232, 241 Taylor, D.V., 28, 36 Taylor, F.W., 48, 51 Taylor, L.W., 158, 164 Taylor, R.G., 191, 198 Telford, K.M., 161, 164 Teloh, H.A., 48, 51 Teneff, S,, 291, 297 Terry, R.A., 62, 70 Teschendorf, R., 4, 12 Thatcher, H.V.H., 250, 264 Thatcher, H.V., 227, 259 Thelander, H.E., 27, 35 Thibaudeau, R., 90, 109 Thiele, G.H., 195, 200 Thomas, A., 105, H5 Thomas, D.F., 252, 265 Thomas, L.I., 80, 84 Thomas, W.W.P., 17, 31 Thompson, C.E., 102, 114 Thompson, F.R., 231, 240 Thompson, T.C., 84 Thomsen, W., 190, 197 Thomson, G.R., 260, 268 Thorndike, A,, 278, 283 Thygesen, P., 88, 108 Tillotson, J.F., 50, 52 Timme, W,, 96, 112 Tinozzi, F.P., 236, 245 Tirman, R.M,, 165• 186 Tohen-Zamudio, A., 89, 109 Tourney, J*, 156, 140 Tourney, J.W., 134,159,178,186 Tourneux, M.J.P., 119, 129 Townley, C.O., 250, 240 Tremblay, G.O., 59, 44 Trevor, D., 215, 224 Trouchet, P., 156, 140 Truhlar, J,, 61, 69 Tschannen, F., 106, 116 Tucker, W.E., 256, 266* Tufo, G.F., 168, 181 Turkish, M,, 40, 44 Turnbull, G.M., 217, 224 Turrettini, A., 5, 12 Tyler, F.H,, 17, 51, 91, 110 Typovsky, K., 218, 224, 232, 241 Ude, W.H., 20, 32 Uiberall, E., 97, 112 Umbreit, W.W., 40, 44 Underwood, G.B., 217, 224 Ungley, C.C., 101, 114 Unkauf, B.M., 228, 259 Upshaw, J.E., 150, 156 Urist, M.R., 50, 52 Vaeye, J., 27, 54 Vails, J., 145, 154 van Creveld, S., 19, 52 Vandenberg, 145, 155 Van Denmark, R.E., 159, 162 Van Der Elst, E., 137, 141 Van de Voorde, C., 126, 131, 138,141 219, 225 Van Dyke, N.M., 294, 298 Van Hove, R., 124, 150 Van Lerenberghe, J,, 5, 15 Van Hess, C.P., 274, 282 Van Wagenen, G,, 9, 15 Vare, V.B., 227, 245 Vargues, R., 115 Vaughan-Jackson, 0.J,, 254, 265 Vecchione, P., 128, 151 Velasco-Zimbrow, A., 155, 159 Vera, A.R., 170, 182 Veebeek, A.D«j., 156, 140 Verbeke, R., 97, 112 Verbiest, H., 106, 116 Verbrugge, J., 27, 55 Verdejo, Y,, 161, 165 Vereecken, E,, 158, 141 Vernet, 58, 45 Vergoz, 252, 265 Vignon, G., 34 Vittori, M,, 255, 266 Vizoso, A*, 14 Vlcek, J*, 166, 180 Vogel, E,, 78, 84 Volpe, L., 270, 280 Von Lackum, W,, 288, 296 Von Ronnen, J.F., 245, 263 Von Ronnen, J.R., 214, 223 Voorde, C., van der, 138, 141 Vosgian, M.E., 61, 69 Vosschulte, K., 171, 182 Wachsmuth, G,, 64, 70 Wahren,>H., 136, 140 Wainwright, W.W., 65, 71 Waisman, R.C., 203, 208 Wakim, K.6., 59, 68, 69 Walch, A., 27, 55 W&lker, A.E., 175, 184 Walker, J.R., 86 Walker, W,, 129 Wallach, E.A., 2, 11 Wallace, P., 158, 141 Walters, B,f 286, 296 Walton, R.J., 143, 155 Ward, R.S., 109 Ward, R., 75, 77, 82, 85 Warrick, C.K., 228, 239 Washburn, A.H., 7, 14 Waters, G,, 98, 108 Watson-rJones, R., 248, 264 Watterson, R.L.’ 58, 68 Waugh, O.S., 177, 186 Waugh, R.L., 253, 265 Weber, L.A., 246, 263 Wedin, P.H., 238, 245 Wegman, M.E., 76, 85 Weidmann, S., 64, 70 Weil, S., 41, 45, 192, 198 Weill, J., 90, 109 Weiner, H.A., 271, 280 Weintraub, S., 54, 67 Weiser, O.L., 40, 45 Weisraan, S.J., 90, 91, 109 Weiss, R.M., 9, 15 Weissenbach, R.J., 202, 208 Welch, C.S., 247, 263 Welte, E., 90, 109 Wentholt, H.W.M., 145, 154 Wenzl, M., 260, 268 Werssowetz, O.F., 279, 284 Wertheimer, P., 237, 243, 270, 280 Wetzel, N.C., 9, 15 Wheelock, M.C., 48, 51 White, M.I., 101, 114 Whittenterger, J.L., 85 Whittico, J., 129 Wiberg, G., 171, 182 Wiedman, J.G., 270, 280 Wieringen, F., van, 14 Wiggins, H.E., 22?, 245 Wilde, C.E., Jr., 8, 14 Wilder, V.M., 62, 70 Wilkins, L., 15 Williams, T.H., 34 Wilson, F.H., 82 Wilson, G.E., 127, 151 Wilson, J.N., 178, 186 Wilson, M.J., 150, 156 Winant, E.K., 211, 223, 231, 240 Winston, B.J., 276, 282 Wiswell, G.B., 95, 110 Wittenborge, M.H., 12 Wolf, J., 206, 210 Wolfson, W.Q., 109 Wolin, I., 221, 226 Wood, J.P., 174, 184 Wooding, C.H.jjr., 2, 11 Woodland, L.J., 18, 31 Woolner, L.B., 260, 268 Wright, L.T., 54, 67 Wustmann, 0., 246, 263 Wycis, H., 176, 185 Yamshon, L.J., 115, 294, 298 Yancey, A.G., 275, 281 Ybarz, P., 178, 186, 255, 241 Yoss, R.E., 96, 112 Youchnovetzki, 105, 115 Young, J.H., 167, 181, 175, 185 Yu, 59, 45 Zabokrzycki, J,, 160, 163 Zadek, I., 178, 186 Zaraecnik, P.C., 7, 14 Zarzecki, C.A., 150, 156 Zatraan, L.J., 59, 88 Zierler, K.L., 61, 69 Zifroni, A., 40, 45 Zimbron, A.V., 159 Zingoni, U., 60, 69 Zippermann, H.H., 48, 51 Zoltan, , 175, 184 Zweighaft, J.F.B., 103, 115 SUBJECT INDEX A Absence, congenital, ilium, 195 Absorbability of hemostatic agents, 57 Acetabulum, fracture, 190 Acetanilide, 58 Acetylcholine, 6I-63 in myasthenia, 90 Achondroplasia, 17 Aclasis, tarso-epiphyseal, 215 Acromioclavicular Joint, 232 Acromion, pseudarthrosis, 218 Acroparaesthesia, 245 Acrylic prosthesis in spine fusion, 136 ACTS, conference, 5^ in myasthenia, 9^ Acute leukemia, l48 Adactar in myasthenia, 9° Adenocarcinoma, embryonal, 159 gluteal, 195 Adenosine triphosphatase, ATP, 6l Adenosine triphosphate, 62, 101 Adrenal cortical function, 57 Adrenal function tests, 55 Adrenals and fatigue, 107 Age, and bone-fat index, 65 Agenesis, ilium, 195 Albers-Schonberg disease, 21 Albright's syndrome, 145, 146 Alcoholic neuritis, foot, 217 Alpha-aminovalerianic acid, 65 Alphatocopherol, 49 American practitioner, 28, 35 Aminopterin in leukemia, l48 Aminopyrine, 58 Amputations, see prostheses Amputation, after care, 279 bandaging stump, 277 brace for strengthening, 276 Callander type, 271 center of gravity, 272 cineplastic, 273, 274 complications, A-V fistula, 276 complications, pain, 275 complications, spondylosis deformans, 272 deformity of femur, 275 embolism, 271 Amputation - cont'd end tearing stumps, 271 forequarter, 272 gangrene, 270 general consideration, 269 hindquarter, 272, 273 hip flexion contracture, 279 history, 269 in Israeli, 279 in Malaya, 279 Krukenberg, 274 Krukenberg-Putti, 274 leprosy, 271 meningococcus gangrene, 271 muscle flaps, 271 muscle sense in cineplasty, 274 neuromata, 275 nursing care, 279 partial foot, 271 peripheral vascular disease, 27O phantom pain, 276 postural considerations, 272 prosthesis, 269-284' refrigeration, 27O scar revision, 276 sensitive scars, 275 site, 4-9 stump treatment, 277 technique, review, 278 thrombo-angitis obliterans, 271 ulceration, 275 Yanghetti's, 274 Amyloidosis, 102 Amyotonia congenita, 89 Amyotrophic lateral sclerosis, 93> 235 Anaesthesia, refrigeration, 270 Anaesthesia complications, brachial block, 247 Anaesthesiology, 58 Anatomic variations, toes, 213 Anatomical aspects of knee, 201 Anatomical variations of pelvis, 194-195 Anatomy, cervical vertebrae, 233 comparative, elbow, 246 hand studies, 259 relation, femoral neck to calcaneus, 206 skeletal, 64 tarsus, 219 Ankle, 219-222 Ankle, ligament injury, 221 meniscoid lesion, 221 osteochondritis dissecans, 221 rupture tendoAchilles, 219 sprain, 219, 221 strapping, 220 synovitis, 221 tendon rupture, 222 tenosynovitis, 221 tibio-f ibular diastasis, 219 x-rays, 220 Ankle and foot, 211-226 Anomalies of carpus, 253 Anterior tibial necrosis, 49 Anterior tibial syndrome, 220 Anthropological studies, hand, 259 Antibodies in milk, 77 Antibodies in poliomyelitis, 73 Anticholinesterase, 6l Antipyretic drugs, 58 Apoplexy, heat, 73 Apparatus, self hoist, 292 splints, 292 for toe flexion, 292 Aran-Duehene disease, 94 Army peripheral nerve register, 98 Arm traction apparatus, 293 Artane in Parkinson's, 97 Arterial constriction, toes, 213 Arteriography, 49 Artero-venous fistula, 49 complication femur stump, 276 Arteriosclerosis, 270 Arthritis, carpometacarpal, 254 cervical, 235 hands, reconstruction, 256-257 hip, 188, 191 inflammatory, hand, 26l knee, 202 shoulder, 231 spine from improper prosthesis, 272 trapezio-metacarpal, 254 trapezio-metacarpal Joint, 255 wrist, 253 Arthrodesis, hip, 189, 192 knee, 137, 204 s aero-iliac, 179 shoulder, 98 trapezio-metacarpal Joint, 253 tubular saw, 291 vertebra, 291 Arthrography, shoulder, 288 Arthrokatadysis, 28 Arthro-onychodysplasia, 2 Arthroplasty, elbow, 136 hip, 46, 136, 189, 193, 194 knee, 136, 204 metacarpophalangeal Joints, 257 metatarsophalangeal Joints, 257 tannin in, 65 Arthrosis, lumbar, 179 Artificial limbs, see prostheses Asbestos splints, 292 Aseptic necrosis, 26, 27 hip, 188, 189, 190 Aspirin, 58 Ataxia, spinal, nutritional, 102 Athetosis, 87 Athletes foot, 218 Athletic injuries, 167 Atlas of neck conditions, 234 Atrophies, 91-94 Atropine in polio, 78 Aureomycin, 65 in polio, 78 Autograft, sciatic, 99 Avascular necrosis, 26, 27 Avitaminosis, and foot pain, 216 B Backache, compensation factors, 166 Bacteriology of poliomyelitis, 73 Bamboo staff for deltoid paralysis, 294 Basket splint for congenital hip, 5 Beeswax, 66 Belladonna in Parkinson's, 96 Benadryl in Parkinson's, 96 Biceps cineplasty, 274 Biochemistry, bone, 65 physiological, 6l Biopsy forceps, 287 Biotin, 65 Bipartite, navicular, 253 Birth trauma, 87 Bis-trimethyl ammonium decrane, 63 Bladder, carcinoma of with bone formation, 152 Blastomycosis, hand, 260 Blood fljDW in toes, 213 Boeck's sarcoid, hand, 260 Bone age, 8 Bone bank, 46, 133, 134, 135 gelatinized bone, 291 Bone changes in paraplegia, 102 Bone cysts, 145, 148 hand, 260 Bone-fat index, 65 Bone formation, 5° Bone graft, 133, 134 gelatinized, 291 Bone growth, 5°, 65 Bone holding forceps, 287 Bone mallet, conical, 287 Bone plate, 289 in spine fusion, 136 Bone structure, 5° Botulinum toxin, 59 Bow legs, 202, 215 Bowleg deformity, 132 Brace, buckles, 293 clubfoot, 294 dynamic, triceps, 294 exercise, 295 in cerebral palsy, 89 Brachial block, complications, 247 Brachial neuralgia, 235, 237 Brachial plexus injury, 97-9$ Breech presentations, 100 Brunhilde polio virus, 73 Buerger's disease, 218 Burns, skeletal suspension, 29O Bursa, suprapatellar, 205 Bursitis, radiohumeral, 246 subacromial, 228 subdeltoid, 228 syphilitic, 17 C C-6, 63 c-10, 63 "Cafe au lait" spots, 149 Caisson disease, hand, 260 hip, 188 Calcaneo-navicular synostosis, 2l4 Calcific deposits, hand, 252 Calcium, level, estrogen effect, 58 level, in serum, 57 level, in testosterone, effect, 58 metabolism, 5° Callosity formation, 202 Callus inhibited by tannin, 65 Canalography, 172 Capsulectomy, for hip pain, 189 metacarpophalangeal Joints, 257 metatarsophalangeal Joints, 257 Capsulitis, shoulder, 229 Carbon dioxide, bicarbonate buffer, 6l Carcinoid tumors, 151 Carcinoma, with bone involvement, 151 clavicle, 232 Carptid denervation, 91# 92 Carpal, congenital defect, 3 ligament syndrome, lunate excision, 252 Cartilage, grafts, semilunar, 202-2014- Cast spreader, 289 Cauda equina tumor, 178 Cavus feet, 2lk Celastic splints, 292 Cellulose, oxidized, 57 Cerebral palsy, see spastics Cerebral palsy, 86-89 causes, 87 classification, 87 diagnosis, 87 ski splints for, 292 treatment, 87, 88 Cervical rib, 237, 238 Cervical vertebrae, anatomy, 233 Charcot knee, 203 Charcot-Marie-Tooth disease, 91 Charcot*s arthritis, hand, 26l Chemistry in multiple sclerosis, 95# 98 Chloromycetin, 65 Chlorophyll, k'J Cholinesterase, 6l Chondro-blastoma, benign, 114-7 Chondro-costal calcification, l6l Chondrodystrophia, foetalis, 17 Chondrogenesis, 65 Chondroitin sulfuric acid, 65 Chondroma, hand, 260 Chondromalacia patella, 205, 206 Chondromatosis, synovial, knee, 203 Chondro-osteoblastoma, Chondro-osteodysplasia, 17 Chondrosarcomatous degeneration, 1^9 Chordoma, lh2, VJO Chordotomy for hip pain, 189 Chronic anterior poliomyelitis, 9^ Chronic backache, 166 Chronic nephritis with finger contractures, 26l Cineplasty, 273, 27^ Circulation, foetal spine, 57 toes, 213 Circulatory defects, 87 Clavicle, axial view, 232 congenital defects, 3 extirpation, 232 Claw toes, 212 "Clay Shoveller’s" fracture, l6l Clinical research, 57 Club foot, 217 brace, 29^ tendon transplants, 7 wedged casts, 7 Coccygodynia, 195 Coccyx, dislocation, 195 Codman's tumor, 1V7 Coefficient, creatin, 6l Coley’s toxins, lh-9, 150 Collagen diseases, 10 Collateral circulation, Compound E, 'jh Compressed air drill and bone cysts, 260 Congenital absence of ilium, 195 Congenital anomalies, 87 Congenital bipartite scaphoid, 253, 2 Congenital deformity, etiology, 1 femur, 275 head and trunk, 3 lower extremities, 6 scope and incidence, 1 systemic anomalies, 2 upper extremities, 2 Congenital dislocation, hip, 192 Congenital dysplasia, hip, 188 Congenital luxation, hip, 188 Congenital parietal dysplasia, 179 Congenital paeudarthrosis, 28 Congenital subluxation, talus, 2lh Contracture, Dupuytren's, 259 et. seq. 5th toe, 213 Volkmann’s, 26l Conversion hysteria, 168 Cortisone, 5^ in myasthenia, 90 Coxalgia, 189 Coxarthrosis, 136, 187 Coxa vara, 27, 28 congenital, 3 Coxitis, 28 Coxsachie polio virus, 74 Cranio-cleido-dysostosis, 3 Creatine-creatinine determinations, 6l Crotonoside, 62 Crouzon’s sign, 100 Crutch walking, 295 Cryptococcosis, 18 Cultures, embryonic, 64 tissue, 55> 64 Cuneiform dislocations, 218 Curare, 6l, 63 in cerebral palsy, 88 in myotonia, 89 in polio, 78 Cushing’s disease, 6l Cushing’s syndrome, 54 Cycliton, 99 Cytochrone C in amyotrophic lateral sclerosis, 94 Cytochrome oxidase, 62 D Darvisul, 79 Decamethonium iodide, 63 in muscular hypertonus, 93 DecuMti, treatment by skeletal suspension, 29O Deformity, see congenital deformity Deformity, congenital, 1 cervical spinous processes, 233 femur, 274, 275 foot and ankle, 138 knee, 202 pelvis, 136 scapula, 233 tibial, 137 toes, 213 upper extremity, 135, 136 Degenerative changes in hip, I87 Dehydrogenase, malic, 62 succinic, 62 Delayed suture, 46 Deltoid paralysis bamboo staff, 294 Denervation of hip, I89 DeQuervain's disease, 251 Dermatology, hands and fingernails, 260 Dermoid implantation, hand, 260 Desoxycorti costerone acetate, 6l Development and growth, see growthf see diseases of growing bone Development and growth, 1 Devices for saw, 287 Diagnostic procedures, 290 Diahydrotachysterol, 19 Diastematomyelia, 4 Dicumarol, 48 Dietary deficiency as cause of congenital deformity, 2 Diparcol in Parkinson’s, 96 Diphtheritic paralysis, 101 Disc, diagnosis hy EMO, 290 cervical, 234 intra-articular, 64 intra-vertehral, 99 Discoid menisci, 204 Disease of hone, hone destruction, 24 hone formation, 20 hereditary, 16 Infections, 17 metabolic, 18 Paget’s disease, 22 Disease, knee, 202 larsen-Johanssen, patella, 206 Dislocation, carpal lunate, 253 carpal scaphoid, 254- coccyx, 195 fihular head, 220 finger, 256 head of radius, Msnteggia, 245 hip, 190 congenital, 192 traumatic, 188, I89 metacarpals, 255 patella, 206 pelvis, 195 shoulder, 230-232 Bankart drill, 288 sterno-clavicular Joint, 232 symphysis puhis, 195 talus, 221 tarso-metatarsal Joint, 218 thumb metacarpal Joint, 254 Disseminated sclerosis, 95 Drilling femoral head, 136 Drugs, antipyretic, 58 in cerebral palsy, 88 Dupuytren's contracture, 259, et. seq. Dwarfism, 2, 16, 17 Dwarfs, sketches of, 2 Dyschondroplasia, 2, 16, 17 Dysplasia, hip, congenital, 188 Itystrophia myotonica, 92 hand, 261 Dystrophy, 91-94 reflex, post-traumatic, 93 E Echinococcus cyst, 178 long hones, 17 vertebrae, 18 Effusion, knee, 202 Ehlers-Danlos syndrome, 2 Elbow, ankylosis, 2k6 arthrodysplasia, 2 arthroplasty, 136, 2k6 epicondyles, 2k6 gunshot wounds, 2h6 loose bodies, 2kk Monteggia fracture, osteochondromatosis, patella cubiti, pseudarthrosis, 2k6 tennis, 2k6 transplant of pectoralis major for flexor, Elbow and forearm, Electrical skin resistance, 75 Electrolytes, serum, 57 Electromyograpny, py, 106, 29O Electrophrenic respiration, 80 Electrophoresis, polio blood, 75 Embolism and amputation, 271 Embryology, 58 knee, 201, 202, 205 sacro-iliac Joints, 178 Embryonic cultures, 6h Encephalitis, allergic, 73 St. Louis, 74 # Enchondral ossification, 65 Endocrine system, 53-55 Endometrial tumors of extremities, Enuresis and retarded bone growth, 10 Eosinophilic granuloma, 29, 14^ Eosinophils, 57 Ependymomas, lk2 Epicondyles, comparative anatomy, 2k6 Epidemiology.of poliomyelitis, 75, 76 Epidemic, poliomyelitis, 72 polio, in Los Angeles, 80 polio, in New York City, 75 polio, in San Diego, 76 polio, in San Francisco, 76 Epidemic, in England and Wales, 76 in Maryland, 81 Epidermo-phytosis, 218 Epinephrine in myotonia, 89 Epiphyseal, slipping, hip, 188 stapling, 10 Epiphysitis, Juvenile, l6l Equalizing leg length, 80 ERB-Goldfam myasthenia, 9°, 109 Estrogen, 55 effect on calcium, 58 Ether, 58 Ethylene diamine tetra-acetic acid, 57 Eulissin, 63 Ewing’s sarcoma, 150 Excision, clavicle, 232 Excision, total, sterno-mastold, 236 Exercise apparatus, 295 Extracts, tissue, 55 •F. Facioscapulohumeral dystrophy, 1? Fanconi syndrome, 19; 20, 25 Fascia lata for tendon repair, 291 Fat-hone index, 65 Feet, congenital defects, 3 club, 7 metatarsal hypertrophy, 6 metatarsus varus, 6 Femoral-calcaneal angle, 207 Femur, fracture after irradiation, 151 fracture of neck, 188 metastasis, 151, 152 Fever therapy in polio, 78 Fihrin foam, 57 Fihrodystrophy, muscular, 92 Fibrosarcoma, 15° humerus, 272 Fibrosis, periarticular, 56 Fibrositis, 167, 168 Fibrous dysplasia, 28, 144, et. seq. Fibula, dislocation, 220 high head, 20k Finger, see hand Finger, anatomical studies, 259 exercises, 256 flexion contractures with nephritis, 26l fractures, 256 infections, 255 metacarpophalangeal joints, 257 metatarsophalangeal Joints, 257 pulp space infections, 255 Finger - cont'd reconstruction, 258 reconstruction of arthritic, 257 splints, 256 Thiermann’s disease, 26l thumb reconstruction, 258 transplant to thumb, 258 transplant from toes, 258 trigger, from collateral ligament, 262 Fingers and hand, 255-262 Fingernail, dermatology treatise, 262 dysplasia, 2 Flail foot, 217 Flat foot, 213 Flavone, 62 Flaxedil, 63 Fluoroscope in shoe stores, 213 Folic acid, 54, 63 Foot, Buerger's disease, 219 dislocations, 218 infection, 218 ingrowing toenail, 218 leprosy, 221 madura, 219 partial amputation, 271 plantar warts, 218 pseudarthrosis, 218 stabilization, 217 trench foot, 219 Foot and ankle, 211-226 Forceps, biopsy, 287 bone holding, 287 Forearm, acroparesthesia, 245 Monteggia fracture, 245 Forearm and hand, 244-268 Forequarter amputation in 1808, 272 Formol toxoid, 101 Fracture, acetabulum, 190 Bennett's, 254 callus, 65 carpal navicular, 253 carpal scaphoid with arthritis, 253 "Clay Shoveller's", l6l compound, osteosynthesis, 119 defects, 332-138 elbow, 121 embolism in, 119 emergency treatment, 117 experimental, of ankle, 127 Fracture - cont'd femur, in children, finger, 256 foot, 127, 128 foot and ankle, 138 forearm, 121 general, 117-120 grafting, 131*, 135 hand, 122 head and trunk, 120 healing research, 119, 120 hip, 122, 123, 12k, 190 hip nailing devices, 286, 287 hip nailing, guide wires, 289 history of, 118 intramedullary fixation, 125, 133 lower extremity, 122 Monteggia, neck of femur, 188 nerve involvement, 135 non-union, 138 non-union of, carpal scaphoid, 253 os calc is, 128 patella, 6, 126, 127, 205 pelvis, 120 radial styloid, 253 tihia, 326 tihial defects, 137 treatment, arm traction, 293 Blade plates, 121 dual slotted plates, 125 external fixation, 119, 122 new pin and stirrup, 288 threaded wires, 121 upper extremity, 120-122 vertebrae, 120 Fracture-dislocation, hip, 123, shoulder, 231, 232 Franceschetti syndrome, 3 Frejka pillow splint, 5 Frozen hone, 133 Fungus infection, foot, 218 vertebrae, 18 Funnel chest, 136 etiology, 3 in military personnel, k surgical treatment, 4 Furmethide in polio, 78 Fusion, knee, 137 G Gangrene, 270 sciatic paralysis, 99 Gaucher’s disease, 29, 1**8 Gelatin sponge, 57 Gelatinized bone, 291 Gelfoam, 57 General paresis, 93 Genu recurvatum, role of rickets, 6 Genu valgum, role of rickets, 6 Genu varum, role of rickets, 6 Giant cell granuloma, knee, 203 Giant cell tumor, > Glomerular filtration, 6l Glomus tumor, 260 Glycogen body, 58, 59 Gonorrhea and knee, 202 Gout, hand, 260, 26l knee, 202 Graft, nerve, 99 Growth, anthropological aspects, 8 development, 1 dietary requirements, 9 diseases of growing bone, 16 experimental work, 8 normal, 7 rates, 55 restriction of bone growth, 9 tendon, 56 tissue, 55-57 Grynfelt*s triangle hernia, 179 Guillain-Barre syndrome, 97 Gunshot wounds, 138 H Hallux rigidus, 212 Hallux valgus, 211 Hallux varus, 212 Hamartoma, hand, 260 Hammer toes, 212 Hand, see fingers Hand, arthrodesis, trapezio-metacarpal Joint, 255 Bennett's fracture, 25^ "blastomycosis, 260 "bone cysts, 260 "brachial block complications, 2kj Hand - cont'd broadening of thumbs, 248 caisson disease, 260 calcific deposits, 252 carpal metacarpal arthritis, 254 compressed air drill disease, 260 congenital deformities, 3 DeQuervain's disease, 251 dislocation, metacarpals, 254 dominance, 8 Dupuytren's contracture, 259> et. seq. dystrophia myotonica, 26l excision trapezium, 255 flexion contractures, 248 gout, 261 hamartoma of palm, 260 hydatid disease, 260 infections, 255 inflammatory rheumatism, 261 lipomata, 26l metacarpophalangeal Joints, 257 metatarsophalangeal Joints, 257 muscles, anomalous innervation, 2k8 neuropathy, median, 247 opponens pollicis paralysis, 249 osteomyelitis, 26l overshoe buckles for brace cuff, 293 pleonosteosis, 248 Raynaud's disease, 247 reconstruction of arthritic, 257 palmar post, 291 sclerodactylta, 247 skin plastic procedure, 257 splints, 256, 293 stenosing tenosynovitis, 251 surgery, 244, 249 general, 256 retractor, 288 surgical repair, thumb metacarpal Joint, 254 tendon grafts, 249 , et. seq. tendon repair, 249 tenosynovitis, suppurative, 255 thumb reconstruction, 258 thumb web repair, 259 trapezio metacarpal arthritis, 254 trigger finger, 251 Volkmann's contracture, 26l yaws, 260 Hand and fingers, 255-262 Hand and forearm, 2M4-268 Hand and nails, dermatology treatise, 262 Hand-Schuller-Christian's disease, 29, lM4, 1*4-5 Hand and wrist, 2*4-7-255 Hardy-WbIff-Goodell, test, 58 Head, congenital defect, 3 Headache, post traumatic, 235 Heat, radiant, test, 58 Hemangioendotheliomas, 1*42 Hemipelvectomy, 272, 273 Hemiplegia after tonsillectomy, 103 Hemostatic agents, 57 Heredity in muscular dystrophy, 91 Hernia, lumbar, 179 Herniated disc, extra lumbar, 160 results of treatment, 177 Herniation, lumbar fat, 170 Hexamethonium bromide, 63 Hindquarter, amputations, 272, 273 Hip, abductor paralysis, 80 anteversion, congenital, 5 arthritis, 188, 191 arthrodesis, 189, 192 arthroplasty, 136, 189, 193> aseptic necrosis, 188 calcifying lesion, 230 capsulectomy for pain, I89 congenital dislocation, 5> 192 in Manitoba Indians, 5 non-surgical treatment, 6 surgical treatment, 5 congenital dysplasia, 188 basis for other entities, 5 early diagnosis, 5 congenital luxation, 188, 189 denervation, I89 dislocations, 190 flexion contracture, amputation for, 279 fractures, 190 Gibson posterior approach, 189, 291 injection of lactic acid for pain, 191 Joint and pelvis, 187-200 Joint disease, 136, 137 myositis ossificans, 190 nailing devices, 286, 287 osteochondritis dissecans, 188 osteochondromatosis, 188 pain, I87-I89 prosthesis for, 189 Hip - cont ’d reconstruction surgery, shelf operation, I89 splint for rotation, 29^ Tavernier's operation, 193 trauma, 190 tuberculosis, 189 Histiocytic granuloma, 14^ Histiocytoma, 1^7 History of poliomyelitis, 72, 73 Hodgkin’s disease, 144, 1^7 Horner's syndrome as complication of brachial block, Huffert's disease, 3° Humerus, epicondyles, 2k6 Hunter's dwarfs, 2, 11 Hyaline cartilage, 65 Hyaluronidase, Jh, 65 Hydatid disease, hand, 260 Hydrarthrosis, knee, 202 Hyperparathyroidism, 28 acromioclavicular changes, 232 hand, 260 Hyperplasia of bone, lM* Hypertensive vascular disease, Hypocalcuria, 25 Hypoxia, 87 I Iliac horns, 2 Iliac spurs, 2 Immunology in poliomyelitis, 73 Index, creatine, 6l fat-bone, 65 Indications for amputation, 269 Infantile cortical hyperostoses, 18, 21 Infantile paralysis, see poliomyelitis Infection, amputation, 27O fingers and hand, 255 knee, 202 pulp space, spine, 178 Injection, lactic acid for hip pain, 191 Injuries of foot, 2l6 Instrument, Bankart drill, 288 biopsy forceps, 287 bone holding forceps, 287 goniometer, 288 mallet, 287 retractor, hand surgery, 288 saw attachment, 287 self retaining retractor, 288 skin grafting, 288 universal stapler, 288 Insulin in muscular dystroihy, 92 Internal derangement, knee, 203 Interscapulothoracic amputation, 272 Intertrochanteric osteotomy, 190 Intervertebral disc, 160, 169, 170> 171 Intocostrln, 88 for phantom limb, 276 Intradural granuloma, 145 Intramedullary lipoma, spinal cord, 145 Intramedullary nail, 46 Intrapelylc protrusion, 28 Iontophoresis for bursitis, 229 Irradiation necrosis, 27 Ischemic necrosis, 26, 27 Ischemic pain, 79 Is og uano s i ne, 62 Israeli, amputations and prosthesis in, 279 J Joint mice, 203 elbow, 244 Joint movement, 611- Joint, sternoclavicular, 232 K Eahler’s disease, 30 Klenboeck's disease, 252, 253 Knee, arthritis, 202 arthrodesis, 20U arthroplasty, 136, 204 closed reduction, loose bodies, 207 contracture in cerebral palsy, 88 deformities, 202 disalfgnment, 6 discoid menisci, 2011- effusion, 202 embryology, 205 flail, 203, 207 fusion, 137 gout, 202 infection, 202 joint, 201-210 anatomical aspects, 201 ligaments, 205 menisci, 201-205 patella, 205-206 quadriceps, 206 synovial membrane, 205 loose body, 203 reconstruction surgery, 2011- rupture of quadriceps, 206 tumors, 203 Knock knee, 202 , 215 Kronecker slide, 6l Krukenberg amputation, 27^ L Lactic acid injection for hip pain, 191 Lambrinudi operation, 99 Laminae, zonal, 63 Laminectomy, 99 tables, 293 Lansing polio virus, 7^ Leg, gravitational 222 Leg length, 137 Legg Perthes disease, 26, 188 Lengthening, leg, 80 operation, 137 Leprosy, foot, 271 talus, 221 Letterer-Siwe*s disease, 29, iW- Leukemia, acute, 1^8 Ligament, collateral, metacarpophalangeal Joints, 257 collateral, metatarsophalangeal Joints, 257 collateral, metacarpophalangeal causing trigger finger, 262 coraco-acromial, 229 foot, 219 Limb fitting, see prosthesis Lipid granulomatosis, iMf Lipoid types tumor, iM- Lipoma, palm, 261 sacral region, 170 Lobectomy for metastasis, 150 Loose body, elbow, 2kk knee, 203 Low back, 165-186 anatomical studies, 165, 166 Low back pain, 195 treatment, 167 Lumbar, arthrosis, 179 fat herniation, 170 hernia, 179 spine, degenerative lesions, 166, 167 venous plexus, 166 Lumbosacral, articulations, 166 fusion, 133y 136 malformations, 178 Lunate, carpal, 253 Luxation, hip, congenital, 188 Lymphogranuloma inguinale and knee, 202 M Manipulation, neck, 233 Madura foot, 219 Magnesium, effect on serum calcium, 57 Malaya, amputations and prostheses, 279 Malformations, lumbosacral, 178 Malic dehydrogenase, 62 Malignant degeneration, Mandible, malignant, tumors of, Manipulative therapy, 167, 176 foot, 213 Marble bones, 21 Marie-Strumpe11 spondylitis, 178 Matrix, of bone, 6k Measurement of pain, 58 Medial malleolus pseudarthrosis, 218 Median nerve neuropathy, 2kj Melanoma, 151, 159 Meningeal hemangioma, 29 Meninges, tumors, Ite Meningitis, 87 influenzae, 101 Meningocele, treatment, k Meningococcaemia and gangrene foot, 271 Meningo-encephalitis, 18 Menisci, 6k Meniscoid lesion, ankle, 221 Metabolic biochemistry, 6l Metabolism, calcium, 50, 55 phosphorus, 50, 55 studies, 5k Metacarpal, congenital deformity, 3 dislocation, 255 Metastases, hand, 260 Metatarsal, hypertrophy, 6 Metatarsalgia, 213 Metatarsus varus, 6 Methyl testosterone, 6l Micromelia, 17 Microradiography, 285 Mongoloids, x-ray studies, k Monteggia fracture, Morquio's disease, 17 Mortality in polio, 79 Morton's toes, Movements, Joints, 6k Multiple myeloma, 150, 151 in Paget's disease, 22, 30 Multiple neurofibromatosis, 1% Multiple sclerosis, 9^ Muscle, anterior tihial syndrome, 220 dystrophy, 62 external oblique, 80 necrosis, 49 nerve preparations, 58-63 physiology, 60 relaxants, 63 rupture pectoralls major, 233 scalenus antlcus syndrome, 236 spasm, 59 sterno-mastoid, excision, 236 strength, 59 striated, 63 transplants in club foot, 7 transplant of pectoralis major, 245 transplant, shoulder, 98 Muscular dystrophy, 6l classification, 91 Muscular fibrodystrophy, 92 Muscular hypertonus, 93 Muscular system, 59-63 Musculus extensor hallucis brevis weakness in l4 discs, 175 Myalgia, acroparesthesia, 245 Myasthenia, congenital, 89 gravis, 89, 9° neonatorum, 89 J^rco-butyricin, 73 Myelograms and peridurograms, 171, et seq Myeloma, multiple, 150 solitary, 151 Myelopathy, 100 Myobilln in muscular dystrophy, 91 Myography, 60 Myopathies, 89-9^ Myosin, 6l Myositis ossificans, blocking hips, 24 hip, 190 malignant degeneration, 149 progressive, 24 Myotonia congenita, 89 N Nail, intramedullary, 133 primary carcinoma of, 152 Navicular fracture, 253 Neck, 233-238 anatomy, 233 arthritis, 235 cervical rih, 237, 238 Neck - cont’d clinical atlas, herniated nucleus pulposus, scalenus syndrome, 236 spasmodic torticollis, 236 stuck Joint syndrome, 236 x-ray, 233 Neck and shoulder, 227 '21*3 Necrosis of muscle, 1*9 Neoplastic hone diseases, 29 Neostigmine, 58 in cerebral palsy, 88 in myasthenia, 89, 91 Nephritis, chronic, with finger contractures, 26l Nerve, anomalous, hand, 2l*8 Army peripheral register, 98 graft, 99 pathway of polio virus, peripheral, injury to, 98 Nerve root, compression syndrome, 29O e ncro achment, 171 pain, 99 Nervous system, trauma to, 97 diseases, varied, Neural arch, ossification of, 195 Neuralgia, cervicohrachial, 23!*, 237 Neurectomy, hip, 189 Neuritis, alcoholic, foot, 217 Neurofibroma, ll*2, 11*6 Neurofibromatosis, 28, ll+9 hand, 260 Neuromata in stumps, 275 Neuromuscular disorders, 86-116 Neuropathy, median, 2l*7 multiple, 103 Neurosurgery for pain, 10l* Neurovascular conditions, hand, 2l*7 New apparatus, devices, procedures, 285-299 Newborn, polio in, 75 New devices, procedures, apparatus, 285-299 New procedures, devices, apparatus, 285-299 Nicotine, 6l Nicotinic acid, 101 Nitrogen, total, 6h Non-union, hip fracture, 190 tibia, 138 Normal growth, 7 Norvalin, 65 Nursing care, amputees, 279 Nursing, self hoist, 2§2 Nylon arthroplasty, knee, 201* 0 Obturator neurectomy, 189 Occupational therapy, 50 Ollier's disease, 16, 17 Operating tables, prone, 293 Orthopedic treatment, cerebral palsy, 88, 89 Orthoroentgenography, 29O Os calcis, fracture, 138 Os purum, grafts in congenital hips, 6 Ossein, 65 Ossification, enchondral, 65 neural arch, 195 Osteitis condensans ilii, 20 Osteitis deformans, 22 Osteitis fibrosa cystica, hand, 260 Osteochondritis dissecans, elbow, 245 hip, 188 shoulder, 232 talus, 221 patella, 206 sacro-iliac, 178 vertebralis, 29 Osteochondromatosis, elbow, 245 hip, 188 Osteoclasis, 132 Osteoclastoma, 147 Osteoclasts, 64 Osteodystrophia fibrosa cystica, 28 Osteogenesis, 63, 64, 65 imperfecta, 2 Osteogenic sarcoma, 143, 149 complication of Paget's, 22 Osteoid-osteoma, 146 Osteolysis, carpal scaphoid, 254 Osteoma, 146 Osteomalacia, 24, 25, 26 Osteomyelitis, 138 hand, 26l hindquarter amputation, 272 Osteopathic treatment, neck pain, 233 Osteopetrosis, 20, 21 Osteopoikilosis, 26 Osteoporosis, 23, 24, 25, 26 Osteosclerosis, 21 Osteosynthesis, see arthrodesis internal fixation fracture treatment Osteosynthesis, 133 Osteotomy, femoral, 137 intertrochanteric, 191 knees, 207 Marziani’s dentate, 132 spine, l60 Otto pelvis, 188 Overlapping fifth toe, 213 p P-31, 64 Paget *s disease, 22, 23, 147 with mental changes, 104 Pain, 104-107 after amputation, 275 ischemic, 79 low hack, 195 measurement, 58 phantom, 276 polio, 79 rectal, 195 relief, 29O Pantothenic acid, 65 Paralysis, agitans, 96 irreversible, 59 median nerve, 247, 248 peripheral nerve, 97, 98, 99 Paraplegia, 145, 178 bone changes in, 102 Parasitic infections, l6l Parasthesia, aero, 245 Patella, 205-226 absence of, 2 cubiti, 247 dislocations, 206 fractures, 205 Larsen, Johanssen disease, 206 rudimentary, 2 Patellectomy, 205, 206 Pathology in poliomyelitis, 75 Peanut oil, 66 Pelvis, anatomy of, 194 deformity, 136 secondary sex differences, 195 Pelvis and hip Joint, 187-200 Penicillin, 66 in polio, 78 Percussion treatment, neuromata, 275 Periodic paralysis, 92 Peripheral vascular conditions, 269, 270 Peritendinitis, ankle, 221 shoulder, 229, 23 0 Perther-Jungllng disease, 29 Perthes disease, 188 Petheosthor, 37 Petit's triangle hernia, 179 Phantom limb, 106 pain, 276 phenacetin, 58 Phenosulfasole, 79 Phenothiazine in Parkinsons, 96 Phlehothromhosis, Phosphorus, excretion, 6l metabolism, 50 radioactive, Gh and carcenogenetic effect, Physical therapy, 80, 8l Physiological biochemistry, 6l Physiology, of muscle, 60 in poliomyelitis, 75 Physostigmine, 6l Pigeon toe, 6 Pituitary insufficiency, 101 Planigraphy and differentiation techniques, 285, 286 Plantar warts, 218 Plastic splints, 292 Plastic surgery, hand, 257 Pleonosteosls, 2^8 Pneumothorax, brachial block, 2^7 Poliomyelitis, see infantile paralysis Poliomyelitis, 72-85 chronic anterior, hip splint, 29^ overshoe buckles for braces, 293 vasospasm in, 97 Polyethylene splints, 292 Polyostotic fibrous dysplasia, 28, 260 Polysyndactylism, 212 Popliteal wound, 99 Position, effect of, on muscle strength, 59, 60 Posterior exposure, hip, 189 Posture, in amputees, 272 in coccygodynla, 195 Potassium, serum level, 57, 93 Potassium serum, in polio, 75 Precipitations, zonal, 63 Prefrontal leukectomy, 115 Pregnancy in multiple sclerosis, 95 Pre-sacral neurectomy for hip pain, 189 Preservation of hone, 133-135 Preventive measures, foot, 216 Priscoline, 79 in polio, 78 Procaine for pain, 290 Prognosis in polio, 81 Progressive muscular atrophy, 91 Pronated feet, 213, 21^ Prostheses, see amputations Prostheses, attachment for short stumps, bent knee, 278 complications, spondylosis deformans, 272 disadvantages of physiological knee, 278 fitting, 277 general, 278 friction in, reducing, 278 hip, I89 in Israeli, 279 in Malaya, 279 material, plastogen, 278 pasteboard, 277 peg leg, 278 replacement, shoulder, 232 slip socket, 277 suction socket, 278 uniaxial knee, 278 walking school, 278 Prostheses and amputations, 269-28U Prostlgmine, 58, 63 effect of on eye, 91 in myotonia, 89 Protein metabolism in growth studies, 7 Pseudarthrosis, 126, 133 elbow, 2^6 foot and shoulder, 218 hip, 190 Pseudocystic disease, iMj- Pseudomonas aeruginosa pyoarthrosis of knee, 203 Psoas abscess, 1/8 Psychiatric therapy, in cerebral palsy, 88 for phantom limb, 276 Psychological test in multiple sclerosis, 95 Psychosomatic back pain, l68 Psychosomatic disorders, musculoskeletal system, 106 Pubis, congenital defects, 3 Puerperal creatinuria, 6l Pulmonary osteoarthropathy, 2k Putti-Krukenberg amputation, 2'jk Pyelosil, arthrograras, 228 Pyridoxine in polio, 78 - Q - Quadriceps, 206 rupture, 206 Quadriplegics, triceps brace, Queckenstedt test, 102 Quinidine in myasthenia, 91 Quinine in myotonia, 89 _ R - Radial nerve involvement, 135 Radial nerve paralysis, 98 Radiant heat test, 58 Radiation, W Radiation therapy, Sudeck's, 105, 106 Radiculitis and EM3-, 29O Radioactive drugs in relation to malignancy, Radioactive phosphorus, 6k Radiography, see x-ray Radiography, myelogram and peridurogram, 172, 173 Radiotherapy in Parkinson's, 96 Radius, congenital defects, 3 hereditary subluxation of head, 2 Raynaud's disease, hand, Recklinghausen's disease, 28 Reconstruction, fingers, 258 hip, surgery, knee, 20k Rectal pain, 195 Reflex dystrophy, 93 Reflexes, deep, leg, 166 Refrigeration, anaesthesia, 27O Rehabilitation, amputee, 279 amputees in Israeli, 279 Renal dysplasia with multiple deformities, 2 Repair, first carpometacarpal Joint, Research, 53-71 clinical, 57 in poliomyelitis, 73-75 Respiration, in polio, 80 Respirator, electrophrenic, 80 Reticulo-endothelial types of tumor, iMf Reticuloendothelioma, 91> 109 Reticuloendothelioses, 29 Reticulo-sarcoma, malignant, IV7 RH factor, 87 Rheumatic fever and knee, 202 Rheumatoid arthritis, 5>k shoulder, 231 Rhizotomy, 79 Ribs, ossification of, 2k Rickets, 19, 20 renal, with genu valgum, 6 Ringworm, foot, 218 Rocker foot, 2lk Roentgenology, see x-ray Root Involvement, 99 Rotator cuff lesions, 228, 232 Rubella as cause of congenital malformations, 2 Rupture, anterior tibial tendon, 222 disc, neck, pectoral!s major, 233 tendoachilles, 219 tendon quadriceps, 206 wrist flexors, 252 s Sacro-iliac, arthritis, 178 embryology, 178 Joint, osteitis condensans llii, 20 Sacrolisthesis, 170 Sarcomas, lk2, ikk Saw, new table attachment, 287 Scaphoid, fracture, 253 pseudarthrosis, 218 Scapula, fixation, 79 snapping, 232 Scapulo-humeral dystrophy, 17 Scapulo-humeral myopathy, 9^ Scar, amputation stumps, 276 contraction, hands, 257 Scheuermann's disease, l6l Sciatic pain, 166-177 Sciatic paralysis, 99 Sclerodactylia, Scleroderma, 28, 29 Sclerotome distribution, 235 Scoliosis, 158, 159, 160 classification, 159 olisthetic, 160 radiation, 159y 160 rotation in, 158 treatment, 159 Scurvy, 56 Selye'» theory, 55 Serology in poliomyelitis, 75 Serum, calcium, 57 electrolytes, 57 electrophoresis, in polio, 75 potassium, 57 Sesamoid, 6h patella cubiti, Sewage, polio virus in, 7^ Sex hormones, 5^ Shelf operation., 189 Shoes, fitting of, 217 Shoulder, anterior approach, 227 arthrodesis, 79 arthrography, 228 bursitis, 228 congenital subluxation, 3 dislocation, 230-232 Bankart drill, 288 fracture-dislocation, 231 frozen, 228 girdle, amputation, 272 injury, 233 osteochondritis, 232 pain, 228 paralytic, 79, 98 periarthritis, 23O prosthetic replacement, 232 rheumatoid arthritis, 231 spica frame, 293 transacromial exposure, 227 x-ray views, 228 Shoulder-arm pain, 233 Shoulder and neck, Silk sutures, 256 Skeletal suspension for decubiti, 29O Skeletal system, 63-65 Skin, electrical resistance, 75 grafting device, 288 grafts, 47 hand, 257 Skis for spastics, 292 Skull, disarticulated, Gk Slipped epiphysis, hip, 188 upper femoral, 27 Slipping rib syndrome, l6l Snapping, finger, 262 scapula, 232 Spasm, muscle, 59 Spastic, aid to walking, 29^ contracture, calf muscles, 127 flat foot, 213 ski splints for, 292 Spastic paralysis, see cerebral palsy Spastic paralysis, 87 overshoe buckles for braces, 293 Speech difficulty and handedness, 8 Spina bifida, 166 occulta with other defects, Spinal, ataxia, nutritional, 102 cord, 100 tumors, 102 epidural space abscesses, ITT fluid studies, 100 fusion, 99, 133, 136, 168, 169, 1T°, 176, ITT tables, 293 Spine, foetal circulation, 5T infections, 178 Splint, Alien-Mason modification, 256 celastic, 292 congenital hip, Frejka, 5 basket, 5 Denis-Browne, clubfoot, 6 hand, 293 hip rotation, knuckle-bender, 256 polyethlene and asbestos, 292 radial, 98 substitute, bamboo staff for deltoid palsy, 29J+ Spondylarthrosis, 166 Spondylitis, ankylosing, 160 cervical, 235 tubercular, 1T8 Spondylolisthesis, 166, 169, 1T°, 195 Spondylosis deformans and improper prosthesis, 2'72 Stabilization, foot, 21T Stapling, epiphyses, 10, k6 Steel sutures, 256, 289 Stenosing tenosynovitis, hand, 25I Sternoclavicular luxation, 232 Steroids, 5^ Stiff neck, 236 Stilbesterol, 55 St. Louis, encephalitis, T^ Stoffel procedure, 12T Stoffel-Silverskjold operation, 103, 10k Stools, polio virus in, T^ Striae, in lumbar arthrosis, 179 Striated muscle, 63 Stuck joint syndrome, 236 Sturge-Weber syndrome, 29, 93 Subluxation, congenital talus, 215 Substance, osteogenetic, Succinic dehydrogenase, 62 Sudeck's syndrome, x-ray treatment, 105, 106 Supra-pateliar bursa, 205 Surgery, in progressive muscular atrophy, 91 in polio, T9 Surgical approach to hip, Gibson, IB9 Surgical table, 293 Surgical technique, wires, 289 Suture, material, 256 wire, 289 Sympathetic surgery for phantom limb, 276 Sympathectomy, 104, 105 Symphysis, horizontal, 195 Syncurine, 63 Syndactylism, multiple, 212 Syndrome, anterior tibial, 220 carpal ligament, 247 scalenus antlcus, 236 stuck joint, 236 supra-clavlcular angle, 237 Synostosis, calcaneo-navicular, 2l4 Synovectomy, hip pain, 189 knee, 205 Synovial membrane, permeability, 54 Synovitis, ankle, 221 Syphilis, 17 general paresis, 93 knee, 202 Syringomyelia, 101 and knee, 202 T Talipes calcaneovalgus, 217 Talo-calcaneal bridge, 2l4 Talus, dislocation, 221 osteochondritis dissecans, 221 vertical, 215 Tannin, in arthroplasty, 65 Tantalum mesh, 48 Tarso-epiphyseal aclasis, 215 Tarso-metatarsal dislocations, 218 Temperature, regulation, 58 Tendinitis, Achilles, 2l6 biceps, 228 suprasplnatus, 228 Tendon, Achilles, rupture, 219 grafts, hand, 249 et seq growth, 56 inflammatory lesions, 221 injury, ankle, 221 repair, hand, 249 with fascia lata, 291 Tendon - cont'd rupture, anterior tiMal, 222 quadriceps, 206 suprasplnatus, 228 wrist flexors, 252 transplants in clubfoot, 7 Teneleryl, 62 Tennis elbow, 246 Tenosynovitis, acute, suppurative, 255 ankle, 221 stenosing, hand, 251 Test, Hardy-WoIff, 58 radiant heat, 58 Testicular, carcinoma with bone metastasis, 152 Testosterone, 62 effect on calcium, 58 methyl, 6l Tetany, 57 Tetraethyl, ammonium chloride for phantom pain, 276 ammonium treatment, 230 pyrophosphate, 6l Thiamine HCl in polio, 78 Thiermann’s disease, fingers, 26l Tbiopentyne, 99 Thoracic discs, 160 Thorax, congenital defects, 3 Thorax and dorsal spine, 158-164 Thorium, 37 Thorn's test, 54, 55 Thrombectomy, 49 Thromboangitis obliterans, 219, 271 Thrombophlebitis, 49 Thumb reconstruction, 258 Thymectomy, 90 Thymoma, 91 Thymus in myasthenia, 9° Thyroid, 6l cancer, 151 Tibia, deformity, 137 non-union, 138 rotation, 6 Tissue, banks, 133, cultures, 55> 64 extracts, 55 growth, 55-57 Tocopherol in amyotrophic lateral sclerosis, 9^ Toe, 211 flexion for walking, 292 Joints in gout, 202 Morton's, 248 pigeon, 6 transplant to hand, 258 Toenail, Ingrowing, 218 Tolserol in cerebral palsy, 88 Tonsillectomy and polio, 76 Topectomy, 113 in Parkinson's, 96 Torticollis, 236 ocularis, 237 spasmodic, 106, 236 Torulosis, 18 Total nitrogen, 64 Toxin, botulinum, 59 Transection of cord, 100 Transillumination of finger tips, 256 Transplant, external oblique, 80 pectoralis major, 245 of tendons in club foot, 7 Trapezium, excision, 255 Trauma, hip, 190 and poliomyelitis, 77 Traumatic neurosis, 168 Treatment of poliomyelitis, 78 Trench foot, 213, 219 Triceps brace, 294 Trigger finger, 251 new concept, 262 Trunk, congenital defect, 3 Tuberculosis, 40 age and race, 38 allergy and immunity, 37, 38 cephalalgia, 38 elbow, 4l general considerations, 37 hand, 260 Hip, 39, 41, 189 knee, 3, 39, 202 laboratory findings, 38 meningitis, 37, 39 neo-antergan, 40 neomycin, 40 pancreatic extract, 40 paraminosalicylic acid, 40 phenergan, 40 promizole, 40 regional considerations, 38 shoulder, 4l spine, 38, 39 sternum, 38 streptomycin in, 39, 43 streptomycin, resistance to, 40 Tuberculosis - cont'd surgery, 4l tenosynovitis, 39 therapy, 37-41 thorotrast, 37, 40 vertebra, 178 Tubocurarin, 63 Tumor, 87, 142-152 cord, 170 Ewing’s, femur, 272 fibrosarcoma, humerus, 272 hand, 260 intraspinal, 142 knee, 203 malignant melanoma, 273 neurofibrosarcoma, thigh, 272 pelvis, 195 spinal cord, 102 trans plantable, 143 u Ulcer, leg, gravitational, 222 Ulna, tfonteggia fracture, 245 Ultrasonic therapy, arthroses, 106 Ultrasound, 234 Upper extremity deformity, 135 Utlease, 62 V Vanghetti’s amputation, 2jk Yaricose ulcer, 222 Varicose veins, 48 Vascular studies, toes, 213 Vascular system, 57, 5& Venous plexus, lumbar, 166 Venous stasis, 48 Venous thrombosis, 49 Vertebra, arthrodesis, 291 cervical, anatomy, 233 congenital deformity, 3, 4 Ewing’s tumor, 150 parasitic infection, l6l plana, 29 Vertebral, infections, 1?8 neural arch, 166 osteotomy, 160 Vertical talus, 214-215 Virus, Brunhilde, 73 Coxsackie, infections, 87 Lansing, mouse, polio, 78 polio, in sewage, 7^ spread in nerve, survival, tests in poliomyelitis, 73 Vitallium, cup, 136 lunate, 253 plate in osteotomy, hip, 137 Vitamin, 8, 9, 18, 19 Vitamin A, 55 Vitamin Bp, 101 Vitamin E, 61 in amyotrophic lateral sclerosis, in Dupuytren's contracture, 259 deficiency, 56 Vocational guidance for amputee, 279 Volkmann's contracture, 62 hand, 26l Von Recklinghausen's disease, 1^9 w Walking heel, 289 Warts, plantar, 218 Wernig-floffman’s muscular dystrophy, 110 Wheelchairs, 295 Wound healing, -48 Wound rupture, Wound, scapular region, 233 Wrist, arthritis with fracture, scaphoid, 253 bipartite navicular, 253 carpal lunate, 252 carpal tunnel syndrome, dislocation of lunate, 253 drop, 252 flexor tendon rupture, 252 fracture radial styloid, 253 Joint, arthrodesis, 252 injuries, 252 navicular fracture, 253 non-union carpal scaphoid, 253 osteolysis of scaphoid, vitallium lunate, 253 Wrist and hand, 2^7-255 X Xanthoma, iM- Xanthomatosis, 29 X-ray, see roentgenology X-ray, first cervical vertebra, 286 hip Joint, lateral, 286 hip profile, 286 lateral, thoracic spine, 286 measurement, lower extremity, 29O microradiography, 285, 286 mounting for fracture table, 287 muscular dystrophy, 92 neck, 233 planigraphy, 285 skull, disarticulated, 6h techniques, 285, 286 variable scale for hip nailing, 28? X-ray therapy, 1^3 giant cell tumor, IV7 Y Yaws, hand, 260 z Zonal laminae, 63 Zonal precipitations, 63 rU. S. GOVERNMENT PRINTING OFFICE : 1957 O - 449057