SURGICAL ANOMALIES OF THE EXTREMITIES.

Reunion of Digits.--An interesting phenomenon noticed in relation to

severed digits is their wonderful capacity for reunion. Restitution of

a severed part, particularly if one of considerable function, naturally

excited the interest of the older writers. Locher has cited an instance

of avulsion of the finger with restitution of the avulsed portion; and

Brulet, Van Esh, Farmer, Ponteau, Regnault, and Rosenberg cite

instances of reunion of a digit after amputation or severance. Eve's

"Remarkable Cases in Surgery" contains many instances of reunion of

both fingers and thumbs, and in more recent years several other similar

cases have been reported. At the Emergency Hospital in Washington,

D.C., there was a boy brought in who had completely severed one of his

digits by a sharp bread-cutter. The amputated finger was wrapped up in

a piece of brown paper, and, being apparently healthy and the wound

absolutely clean, it was fixed in the normal position on the stump, and

covered by a bichlorid dressing. In a short time complete function was

restored. In this instance no joint was involved, the amputation being

in the middle of the 2d phalanx. Staton has described a case in which

the hand was severed from the arm by an accidental blow from an axe.

The wound extended from the styloid process directly across to the

trapezium, dividing all the muscles and blood-vessels, cutting through

bones. A small portion of the skin below the articulation, with the

ulna, remained intact. After an unavoidable delay of an hour, Staton

proceeded to replace the hand with silver sutures, adhesive plaster,

and splints. On the third day pulsation was plainly felt in the hand,

and on the fourteenth day the sutures were removed. After some time the

patient was able to extend the fingers of the wounded member, and

finally to grasp with all her wonted strength.

The reproduction or accidental production of nails after the original

part has been torn away by violence or destroyed by disease, is quite

interesting. Sometimes when the whole last phalanx has been removed,

the nail regrows at the tip of the remaining stump. Tulpius seems to

have met with this remarkable condition. Marechal de Rougeres, Voigtel,

and Ormancey have related instances of similar growths on the 2d

phalanx after the loss of the 1st. For several months a woman had

suffered from an ulcer of the middle finger of the right hand, in

consequence of a whitlow; there was loss of the 3d phalanx, and the

whole of the articular surface and part of the compact bony structure

of the 2d. On examining the sore, Ormangey saw a bony sequestrum which

appeared to keep it open. He extracted this, and, until cicatrization

was complete, he dressed the stump with saturnine cerate. Some months

afterward Ormangey saw with astonishment that the nail had been

reproduced; instead of following the ordinary direction, however, it

lay directly over the face of the stump, growing from the back toward

the palmer aspect of the stump digit, as if to cover and protect the

stump. Blandin has observed a case of the same description. A third

occurred at the Hopital de la Charite, in a woman, who, in consequence

of a whitlow, had lost the whole of the 3d phalanx of one of the

forefingers. The soft and fleshy cushion which here covered the 2d

phalanx was terminated by a small, blackish nail, like a grain of spur

rye. It is probable that in these cases the soft parts of the 3d

phalanx, and especially the ungual matrix, had not been wholly

destroyed. In his lectures Chevalier speaks of analogous cases.

In some instances avulsion of a finger is effected in a peculiar

manner. In 1886 Anche reported to his confreres in Bordeaux a rare

accident of this nature that occurred to a carpenter. The man's finger

was caught between a rope and the block of a pulley. By a sudden and

violent movement on his part he disengaged the hand but left the 3d

finger attached to the pulley. At first examination the wound looked

like that of an ordinary amputation by the usual oval incision; from

the center of the wound the proximal fragment of the 1st phalanx

projected. Polaillon has collected 42 similar instances, in none of

which, however, was the severance complete.

It occasionally happens that in avulsion of the finger an entire tendon

is stripped up and torn off with the detached member. Vogel describes

an instance of this nature, in which the long flexor of the thumb was

torn off with that digit. In the Surgical Museum at Edinburgh there is

preserved a thumb and part of the flexor longus pollicis attached,

which were avulsed simultaneously. Nunnely has seen the little finger

together with the tendon and body of the longer flexor muscle avulsed

by machinery. Stone details the description of the case of a boy named

Lowry, whose left thumb was caught between rapidly twisting strands of

a rope, and the last phalanx, the neighboring soft parts, and also the

entire tendon of the flexor longus pollicis were instantly torn away.

There was included even the tendinous portion of that small slip of

muscle taking its origin from the anterior aspect of the head and upper

portion of the ulna, and which is so delicate and insignificant as to

be generally overlooked by anatomists. There was great pain along the

course of the tract of abstraction of the tendon.

Pinkerton describes a carter of thirty-one who was bitten on the thumb

by a donkey. The man pulled violently in one direction, and the donkey,

who had seized the thumb firmly with his teeth, pulled forcibly in the

other direction until the tissues gave way and the man ran off, leaving

his thumb in the donkey's mouth. The animal at once dropped the thumb,

and it was picked up by a companion who accompanied the man to the

hospital. On examination the detached portion was found to include the

terminal phalanx of the thumb, together with the tendon of the flexor

longus pollicis measuring ten inches, about half of which length had a

fringe of muscular tissue hanging from the free borders, indicating the

extent and the penniform arrangement of the fibers attached to it.

Meyer cites a case in which the index finger was torn off and the

flexor muscle twisted from its origin. The authors know of an

unreported case in which a man running in the street touched his hand

to a hitching block he was passing; a ring on one of his fingers caught

in the hook of the block, and tore off the finger with the attached

tendon and muscle. There is a similar instance of a Scotch gentleman

who slipped, and, to prevent falling, he put out his hand to catch the

railing. A ring on one of his fingers became entangled in the railing

and the force of the fall tore off the soft parts of the finger

together with the ring.

The older writers mentioned as a curious fact that avulsion of the arm,

unaccompanied by hemorrhage, had been noticed. Belchier, Carmichael,

and Clough report instances of this nature, and, in the latter case,

the progress of healing was unaccompanied by any uncomfortable

symptoms. In the last century Hunezoysky observed complete avulsion of

the arm by a cannon-ball, without the slightest hemorrhage. The

Ephemerides contains an account of the avulsion of the hand without any

bleeding, and Woolcomb has observed a huge wound of the arm from which

hemorrhage was similarly absent. Later observations have shown that in

this accident absence of hemorrhage is the rule and not the exception.

The wound is generally lacerated and contused and the mouths of the

vessels do not gape, but are twisted and crushed. The skin usually

separates at the highest point and the muscles protrude, appearing to

be tightly embraced and almost strangulated by the skin, and also by

the tendons, vessels, and nerves which, crushed and twisted with the

fragments of bone, form a conical stump. Cheselden reports the history

of a case, which has since become classic, that he observed in St.

Thomas' Hospital in London, in 1837. A miller had carelessly thrown a

slip-knot of rope about his wrist, which became caught in a revolving

cog, drawing him from the ground and violently throwing his body

against a beam. The force exerted by the cog drawing on the rope was

sufficient to avulse his whole arm and shoulder-blade. There was

comparatively little hemorrhage and the man was insensible to pain;

being so dazed and surprised he really was unconscious of the nature of

his injury until he saw his arm in the wheel.

According to Billroth the avulsion of an arm is usually followed by

fatal shock. Fischer, however, relates the case of a lion-tamer whose

whole left arm was torn from the shoulder by a lion; the loss of blood

being very slight and the patient so little affected by shock that he

was able to walk to the hospital.

Mussey describes a boy of sixteen who had his left arm and

shoulder-blade completely torn from his body by machinery. The patient

became so involved in the bands that his body was securely fastened to

a drum, while his legs hung dangling. In this position he made about 15

revolutions around the drum before the motion of the machinery could be

effectually stopped by cutting off the water to the great wheel. When

he was disentangled from the bands and taken down from the drum a huge

wound was seen at the shoulder, but there was not more than a pint of

blood lost. The collar-bone projected from the wound about half an

inch, and hanging from the wound were two large nerves (probably the

median and ulnar) more than 20 inches long. He was able to stand on

his feet and actually walked a few steps; as his frock was opened, his

arm, with a clot of blood, dropped to the floor. This boy made an

excellent recovery. The space between the plastered ceiling and the

drum in which the revolutions of the body had taken place was scarcely

7 1/2 inches wide. Horsbeck's case was of a negro of thirty-five who,

while pounding resin on a 12-inch leather band, had his hand caught

between the wheel and band. His hand, forearm, arm, etc., were rapidly

drawn in, and he was carried around until his shoulder came to a large

beam, where the body was stopped by resistance against the beam, fell

to the floor, and the arm and scapula were completely avulsed and

carried on beyond the beam. In this case, also, the man experienced

little pain, and there was comparatively little hemorrhage. Maclean

reports the history of an accident to a man of twenty-three who had

both arms caught between a belt and the shaft while working in a woolen

factory, and while the machinery was in full operation. He was carried

around the shaft with great velocity until his arms were torn off at a

point about four inches below the shoulder-joint on each side. The

patient landed on his feet, the blood spurting from each brachial

artery in a large stream. His fellow-workmen, without delay, wound a

piece of rope around each bleeding member, and the man recovered after

primary amputation of each stump. Will gives an excellent instance of

avulsion of the right arm and scapula in a girl of eighteen, who was

caught in flax-spinning machinery. The axillary artery was seen lying

in the wound, pulsating feebly, but had been efficiently closed by the

torsion of the machinery. The girl recovered.

Additional cases of avulsion of the upper extremity are reported by

Aubinais, Bleynie, Charles, George, James, Jones, Marcano, Belchier,

Braithwaite, and Hendry.

Avulsion of the Lower Extremity.--The symptoms following avulsion of

the upper extremity are seen as well in similar accidents to the leg

and thigh, although the latter are possibly the more fatal. Horlbeck

quotes Benomont's description of a small boy who had his leg torn off

at the knee by a carriage in motion; the child experienced no pain, and

was more concerned about the punishment he expected to receive at home

for disobedience than about the loss of his leg. Carter speaks of a boy

of twelve who incautiously put the great toe of his left foot against a

pinion wheel of a mill in motion. The toe was fastened and drawn into

the mill, the leg following almost to the thigh. The whole left leg and

thigh, together with the left side of the scrotum, were torn off; the

boy died as a result of his injuries.

Ashurst reported to the Pathological Society of Philadelphia the case

of a child of nine who had its right leg caught in the spokes of a

carriage wheel. The child was picked up unconscious, with its thigh

entirely severed, and the bone broken off about the middle third; about

three inches higher the muscles were torn from the sheaths and appeared

as if cut with a knife. The great sciatic nerve was found hanging 15

inches from the stump, having given way from its division in the

popliteal space. The child died in twelve hours. One of the most

interesting features of the case was the rapid cooling of the body

after the accident and prolongation of the coolness with slight

variations until death ensued. Ashurst remarks that while the cutaneous

surface of the stump was acutely sensitive to the touch, there was no

manifestation of pain evinced upon handling the exposed nerve.

With reference to injuries to the sciatic nerve, Kuster mentions the

case of a strong man of thirty, who in walking slipped and fell on his

back. Immediately after rising to his feet he felt severe pain in the

right leg and numbness in the foot. He was unable to stand, and was

carried to his house, where Kuster found him suffering great pain. The

diagnosis had been fracture of the neck of the femur, but as there was

no crepitation and passive movements caused but little pain, Kuster

suspected rupture of the sciatic nerve. The subsequent history of the

case confirmed this diagnosis. The patient was confined to bed six

weeks, and it was five months afterward before he was able to go about,

and then only with a crutch and a stick.

Park mentions an instance of rupture of the sciatic nerve caused by a

patient giving a violent lurch during an operation at the hip-joint.

The instances occasionally observed of recovery of an injured leg after

extensive severance and loss of substance are most marvelous. Morton

mentions a boy of sixteen, who was struck by one of the blades of a

reaping machine, and had his left leg cut through about 1 1/4 inches

above the ankle-joint. The foot was hanging by the portion of skin

corresponding to the posterior quarter of the circumference of the leg,

together with the posterior tibial vessels and nerves. These were the

only structures escaping division, although the ankle-joint itself was

intact. There was comparatively little hemorrhage and no shock; a

ligature was applied to the vessels, the edges of the wound were drawn

together by wire sutures, and the cut surfaces of the tibia were placed

in as good apposition as possible, although the lower fragment

projected slightly in front of the upper. The wound was dressed and

healing progressed favorably; in three months the wound had filled up

to such an extent that the man was allowed to go on crutches. The

patient was discharged in five months, able to walk very well, but

owing to the loss of the function of the extensor tendons the toes

dragged.

Washington reports in full the case of a boy of eleven, who, in handing

a fowling piece across a ditch, was accidentally shot. The contents of

the gun were discharged through the leg above the ankle, carrying away

five-sixths of the structure--at the time of the explosion the muzzle

of the gun was only two feet away from his leg. The portions removed

were more than one inch of the tibia and fibula (irregular fractures of

the ends above and below), a corresponding portion of the posterior

tibial muscle, and the long flexors of the great and small toes, as

well as the tissue interposed between them and the Achilles tendon. The

anterior tibial artery was fortunately uninjured. The remaining

portions consisted of a strip of skin two inches in breadth in front of

the wound, the muscles which it covered back of the wound, the Achilles

tendon, and another piece of skin, barely enough to cover the tendon.

The wound was treated by a bran-dressing, and the limb was saved with a

shortening of but 1 1/2 inches.

There are several anomalous injuries which deserve mention. Markoe

observed a patient of seventy-two, who ruptured both the quadriceps

tendons of each patella by slipping on a piece of ice, one tendon first

giving way, and followed almost immediately by the other. There was the

usual depression immediately above the upper margin of the patella, and

the other distinctive signs of the accident. In three months both

tendons had united to such an extent that the patient was able to walk

slowly. Gibney records a case in which the issue was not so successful,

his patient being a man who, in a fall ten years previously, had

ruptured the right quadriceps tendon, and four years later had suffered

the same accident on the opposite side. As a result of his injuries, at

the time Gibney saw him, he had completely lost all power of extending

the knee-joint. Partridge mentions an instance, in a strong and healthy

man, of rupture of the tendon of the left triceps cubiti, caused by a

fall on the pavement. There are numerous cases in which the tendo

Achillis has recovered after rupture,--in fact, it is unhesitatingly

severed when necessity demands it, sufficient union always being

anticipated. None of these cases of rupture of the tendon are unique,

parallel instances existing in medical literature in abundance.

Marshall had under his observation a case in which the femoral artery

was ruptured by a cart wheel passing over the thigh, and death ensued

although there were scarcely any external signs of contusion and

positively no fracture. Boerhaave cites a curious instance in which a

surgeon attempted to stop hemorrhage from a wounded radial artery by

the application of a caustic, but the material applied made such

inroads as to destroy the median artery and thus brought about a fatal

hemorrhage.

Spontaneous fractures are occasionally seen, but generally in advanced

age, although muscular action may be the cause. There are several cases

on record in which the muscular exertion in throwing a stone or ball,

or in violently kicking the leg, has fractured one or both of the bones

of an extremity. In old persons intracapsular fracture may be caused by

such a trivial thing as turning in bed, and even a sudden twist of the

ankle has been sufficient to produce this injury. In a boy of thirteen

Storrs has reported fracture of the femur within the acetabulum. In

addition to the causes enumerated, inflammation of osseous tissue, or

osteoid carcinoma, has been found at the seat of a spontaneous fracture.

One of the most interesting subjects in the history of surgery is the

gradual evolution of the rational treatment of dislocations. Possibly

no portion of the whole science was so backward as this. Thirty-five

centuries ago Darius, son of Hydaspis, suffered a simple luxation of

the foot; it was not diagnosed in this land of Apis and of the deified

discoverer of medicine. Among the wise men of Egypt, then in her acme

of civilization, there was not one to reduce the simple luxation which

any student of the present day would easily diagnose and successfully

treat. Throughout the dark ages and down to the present century, the

hideous and unnecessary apparatus employed, each decade bringing forth

new types, is abundantly pictured in the older books on surgery; in

some almost recent works there are pictures of windlasses and of

individuals making superhuman efforts to pull the luxated member

back--all of which were given to the student as advisable means of

treatment.

Relative to anomalous dislocations the field is too large to be

discussed here, but there are two recent ones worthy of mention.

Bradley relates an instance of death following a subluxation of the

right humerus backward on the scapula It could not be reduced because

the tendon of the biceps lay between the head of the humerus and a

piece of the bone which was chipped off.

Baxter-Tyrie reports a dislocation of the shoulder-joint, of unusual

origin, in a man who was riding a horse that ran away up a steep hill.

After going a few hundred yards the animal abated its speed, when the

rider raised his hand to strike. Catching sight of the whip, the horse

sprang forward, while the man felt an acute pain and a sense of

something having given way at his shoulder. He did not fall off, but

rode a little further and was helped to dismount. On examination a

subcoracoid dislocation of the head of the humerus was found. The

explanation is that as the weight of the whip was inconsiderable (four

ounces) the inertia of the arm converted it into a lever of the first

order. Instead of fulfilling its normal function of preventing

displacement, the coraco-acromial arch acted as a fulcrum. The limb

from the fingers to that point acted as the "long arm," and the head

and part of the neck of the humerus served as the "short arm." The

inertia of the arm, left behind as it were, supplied the power, while

the ruptured capsular ligament and displacement of the head of the bone

would represent the work done.

Congenital Dislocations.--The extent and accuracy of the knowledge

possessed by Hippocrates on the subject of congenital dislocations have

excited the admiration of modern writers, and until a comparatively

recent time examples of certain of the luxations described by him had

not been recorded. With regard, for instance, to congenital

dislocations at the shoulder-joint, little or nothing was known save

what was contained in the writings of Hippocrates, till R. M. Smith and

Guerin discussed the lesion in their works.

Among congenital dislocations, those of the hips are most common--in

fact, 90 per cent of all. They are sometimes not recognizable until

after the lapse of months and sometimes for years, but their

causes--faulty developments of the joint, paralysis, etc.--are supposed

to have existed at birth. One or both joints may be involved, and

according to the amount of involvement the gait is peculiar. As to the

reduction of such a dislocation, the most that can be done is to

diminish the deformity and functional disability by traction and

palliative measures with apparatus. The normal structure of the joint

does not exist, and therefore the dislocation admits of no reduction.

Congenital dislocations of the shoulder are also seen, owing to faulty

development of the glenoid fossa; and at the knee, the leg generally

being in extreme hyperextension, the foot sometimes resting on the

abdomen. Congenital luxation of the femora, when it appears in adult

women is a prominent factor in dystocia. There is a dislocation found

at birth, or occurring shortly after, due to dropsy of the joint in

utero; and another form due to succeeding paralysis of groups of

muscles about the joint.

The interesting instances of major amputations are so numerous and so

well known as to need no comment here. Amputation of the hip with

recovery is fast becoming an ordinary operation; at Westminster

Hospital in London, there is preserved the right humerus and scapula,

presenting an enormous bulk, which was removed by amputation at the

shoulder-joint, for a large lymphosarcoma growing just above the

clavicle. The patient was a man of twenty-two, and made a good

recovery. Another similar preparation is to be seen in London at St.

Bartholomew's Hospital.

Simultaneous, synchronous, or consecutive amputations of all the limbs

have been repeatedly performed. Champeuois reports the case of a

Sumatra boy of seven, who was injured to such an extent by an explosion

as to necessitate the amputation of all his extremities, and, despite

his tender age and the extent of his injuries, the boy completely

recovered. Jackson, quoted by Ashhurst, had a patient from whom he

simultaneously amputated all four limbs for frost-bite.

Muller reports a case of amputation of all four limbs for frost-bite,

with recovery. The patient, aged twenty-six, while traveling to his

home in Northern Minnesota, was overtaken by a severe snow storm, which

continued for three days; on December 13th he was obliged to leave the

stage in a snow-drift on the prairie, about 110 miles distant from his

destination. He wandered over the prairie that day and night, and the

following four days, through the storm, freezing his limbs, nose, ears,

and cheeks, taking no food or water until, on December 16th, he was

found in a dying condition by Indian scouts, and taken to a

station-house on the road. He did not reach the hospital at Fort

Ridgely until the night of December 24th--eleven days after his first

exposure. He was almost completely exhausted, and, after thawing the

ice from his clothes, stockings, and boots,--which had not been removed

since December 13th,--it was found that both hands and forearms were

completely mortified up to the middle third, and both feet and legs as

far as the upper third; both knees over and around the patellae, and

the alae and tip of the nose all presented a dark bluish appearance and

fairly circumscribed swelling. No evacuation of the bowels had taken

place for over two weeks, and as the patient suffered from singultus

and constant pain over the epigastric region, a light cathartic was

given, which, in twenty-four hours, gave relief. The four frozen limbs

were enveloped in a solution of zinc chlorid. The frozen ears and

cheeks healed in due time, and the gangrenous parts of the nose

separated and soon healed, with the loss of the tip and parts of the

alae, leaving the septum somewhat exposed. On January 10th the lines of

demarcation were distinct and deep on all four limbs, though the

patient, seconded by his wife, at first obstinately opposed operative

interference; on January 13th, after a little hesitancy, the man

consented to an amputation of the arms. This was successfully carried

out on both forearms, at the middle third, the patient losing hardly

any blood and complaining of little pain. The great relief afforded by

this operation so changed his aversion to being operated upon that on

the next day he begged to have both legs amputated in the same manner,

which was done, three days afterward, with the same favorable result.

After some minor complications the patient left for his home, perfectly

recovered, June 9, 1866.

Begg of Dundee successfully performed quadruple amputation on a woman,

the victim of idiopathic gangrene. With artificial limbs she was able

to earn a livelihood by selling fancy articles which she made herself.

This woman died in 1885, and the four limbs, mounted on a lay figure,

were placed in the Royal College of Surgeons, in London. Wallace, of

Rock Rapids, Iowa, has successfully removed both forearms, one leg, and

half of the remaining foot, for frost-bite. Allen describes the case of

a boy of eight who was run over by a locomotive, crushing his right

leg, left foot, and left forearm to such an extent as to necessitate

primary triple amputation at the left elbow, left foot, and right leg,

the boy recovering. Ashhurst remarks that Luckie, Alexander, Koehler,

Lowman, and Armstrong have successfully removed both legs and one arm

simultaneously for frost-bite, all the patients making excellent

recoveries in spite of their mutilations; he adds that he himself has

successfully resorted to synchronous amputation of the right hip-joint

and left leg for a railroad injury occurring in a lad of fifteen, and

has twice synchronously amputated three limbs from the same patient,

one case recovering.

Wharton reports a case of triple major amputation on a negro of

twenty-one, who was run over by a train. His right leg was crushed at

the knee, and the left leg crushed and torn off in the middle third;

the right forearm and hand were crushed. In order to avoid chill and

exposure, he was operated on in his old clothes, and while one limb was

being amputated the other was being prepared. The most injured member

was removed first. Recovery was uninterrupted.

There are two cases of spontaneous amputation worthy of record.

Boerhaave mentions a peasant near Leyden, whose axillary artery was

divided with a knife, causing great effusion of blood, and the patient

fainted. The mouth of the vessel was retracted so far as to render

ligature impossible, and the poor man was abandoned to what was

considered an inevitable fate by his unenlightened attendants.

Expecting to die every moment, he continued several days in a languid

state, but the hemorrhage ceased spontaneously, and the arm decayed,

shrunk, and dried into a mummified stump, which he carried about for

quite a while. Rooker speaks of a fracture of the forearm, near the

lower part of the middle third, in a patient aged fourteen. Incipient

gangrene below the seat of fracture, with associate inflammation,

developed; but on account of the increasing gangrene it was determined

to amputate. On the fifth day the line of demarcation extended to the

spine of the scapula, laying bare the bone and exposing the acromion

process and involving the pectoral muscles. It was again decided to let

Nature continue her work. The bones exfoliated, the spine and the

acromial end of the scapula came away, and a good stump was formed.

Figure 212 represents the patient at the age of twenty-eight.

By ingenious mechanical contrivances persons who have lost an extremity

are enabled to perform the ordinary functions of the missing member

with but slight deterioration. Artificial arms, hands, and legs have

been developed to such a degree of perfection that the modern

mechanisms of this nature are very unlike the cumbersome and intricate

contrivances formerly used.

Le Progres Medical contains an interesting account of a curious contest

held between dismembered athletes at Nogent-Sur-Marne, a small town in

the Department of the Seine, in France. Responding to a general

invitation, no less than seven individuals who had lost either leg or

thigh, competed in running races for prizes. The enterprising cripples

were divided into two classes: the cuissards, or those who had lost a

thigh, and jambards, or those who had lost a leg; and, contrary to what

might have been expected, the grand champion came from the former

class. The distance in each race was 200 meters. M. Roullin, whose

thigh, in consequence of an accident, was amputated in 1887, succeeded

in traversing the course in the remarkable time of thirty seconds

(about 219 yards); whereas M. Florrant, the speediest jambard, required

thirty-six seconds to run the same distance; and was, moreover,

defeated by two other cuissards besides the champion. The junior race

was won in thirty-five seconds, and this curious day's sport was ended

by a course de consolation, which was carried off in thirty-three

seconds by M. Mausire, but whether he was a cuissard or a jambard was

not stated.

On several occasions in England, cricket matches have been organized

between armless and legless men. In Charles Dickens' paper, "All the

Year Round," October 5, 1861, there is a reference to a cricket match

between a one-armed eleven and a one-legged eleven. There is a recent

report from De Kalb, Illinois, of a boy of thirteen who had lost both

legs and one arm, but who was nevertheless enabled to ride a bicycle

specially constructed for him by a neighboring manufacturer. With one

hand he guided the handle bar, and bars of steel attached to his stumps

served as legs. He experienced no trouble in balancing the wheel; it is

said that he has learned to dismount, and soon expects to be able to

mount alone; although riding only three weeks, he has been able to

traverse one-half a mile in two minutes and ten seconds. While the

foregoing instance is an exception, it is not extraordinary in the

present day to see persons with artificial limbs riding bicycles, and

even in Philadelphia, May 30, 1896, there was a special bicycle race

for one-legged contestants.

The instances of interesting cases of foreign bodies in the extremities

are not numerous. In some cases the foreign body is tolerated many

years in this location. There are to-day many veterans who have bullets

in their extremities. Girdwood speaks of the removal of a foreign body

after twenty-five years' presence in the forearm. Pike mentions a man

in India, who, at the age of twenty-two, after killing a wounded hare

in the usual manner by striking it on the back of the neck with the

side of the hand, noticed a slight cut on the hand which soon healed

but left a lump under the skin. It gave him no trouble until two months

before the time of report, when he asked to have the lump removed,

thinking it was a stone. It was cut down upon and removed, and proved

to be the spinous process of the vertebra of a hare. The bone was

living and healthy and had formed a sort of arthrodial joint on the

base of the phalanx of the little finger and had remained in this

position for nearly twenty-two years.

White has described a case in which a nail broken off in the foot,

separated into 26 splinters, which, after intense suffering, were

successfully removed. There was a case recently reported of a man

admitted to the Bellevue Hospital, New York, whose arm was supposed to

have been fractured by an explosion, but instead of which 11 feet of

lead wire were found in it by the surgeons. The man was a machinist in

the employ of the East River Lead Co., and had charge of a machine

which converted molten lead into wire. This machine consists of a steel

box into which the lead is forced, being pressed through an aperture

1/8 inch in diameter by hydraulic pressure of 600 tons. Reaching the

air, the lead becomes hard and is wound on a large wheel in the form of

wire. Just before the accident this small aperture had become clogged,

and the patient seized the projecting wire in his hand, intending to

free the action of the machine, as he had previously done on many

occasions, by a sharp, strong pull; but in so doing an explosion

occurred, and he was hurled to the floor unconscious. While on the way

to the hospital in the ambulance, he became conscious and complained of

but little pain except soreness of the left arm about the elbow. The

swelling, which had developed very rapidly, made it impossible for the

surgeons to make an examination, but on the following day, when the

inflammation had subsided sufficiently, a diagnosis of fracture of the

bones of the arm was made. There was no external injury of the skin of

any magnitude, and the surgeons decided to cut down on the trifling

contusion, and remove what appeared to be a fragment of bone, lodged

slightly above the wrist. An anesthetic was administered, and an

incision made, but to the amazement of the operators, instead of bone,

a piece of wire one inch in length and 1/8 inch in diameter was

removed. On further exploration piece after piece of the wire was taken

out until finally the total length thus removed aggregated 11 feet, the

longest piece measuring two feet and the shortest 1/4 inch. The wire

was found imbedded under the muscles of the arm, and some of it had

become wedged between the bones of the forearm. Probably the most

remarkable feature of this curious accident was the fact that there was

no fracture or injury to the bone, and it was thought possible that the

function of the arm would be but little impaired.

Tousey reports a case of foreign body in the axilla that was taken for

a necrotic fragment of the clavicle. The patient was a boy of sixteen,

who climbed up a lamp-post to get a light for his bicycle lamp; his

feet slipped off the ornamental ledge which passed horizontally around

the post about four feet from the ground, and he fell. In the fall a

lead pencil in his waistcoat pocket caught on the ledge and was driven

into the axilla, breaking off out of sight. This was supposed to be a

piece of the clavicle, and was only discovered to be a pencil when it

was removed six weeks after.

There are several diseases of the bone having direct bearing on the

anomalies of the extremities which should have mention here.

Osteomalacia is a disease of the bones in adult life, occurring most

frequently in puerperal women, but also seen in women not in the

puerperal state, and in men. It is characterized by a progressive

softening of the bone-substance, from a gradual absorption of the lime

salts, and gives rise to considerable deformity, and occasionally to

spontaneous fracture.

Rachitis or rickets is not a disease of adult life, but of infancy and

childhood, and never occurs after the age of puberty. It seldom begins

before six months or after three years. There are several theories as

to its causation, one being that it is due to an abnormal development

of acids. There is little doubt that defective nutrition and bad

hygienic surroundings are prominent factors in its production. The

principal pathologic change is seen in the epiphyseal lines of long

bones and beneath the periosteum. Figure 213 shows the appearance

during life of a patient with the highest grade of rachitis, and it can

be easily understood what a barrier to natural child-birth it would

produce. In rachitis epiphyseal swellings are seen at the wrists and

ankle-joints, and in superior cases at the ends of the phalanges of the

fingers and toes. When the shaft of a long bone is affected, not only

deformity, but even fracture may occur. Under these circumstances the

humerus and femur appear to be the bones most likely to break; there is

an associate deformity of the head, known as "craniotabes," together

with pigeon-breast and various spinal curvature. The accompanying

illustration is from a drawing of a skeleton in the Warren Museum in

Boston. The subject was an Indian, twenty-one years of age, one of the

Six Nations. His mode of locomotion was by a large wooden bowl, in

which he sat and moved forward by advancing first one side of the bowl

and then the other, by means of his hands. The nodules or "adventitious

joints" were the result of imperfect ossification, or, in other words,

of motion before ossification was completed.

Analogous to rachitis is achondroplasia, or the so called fetal

rickets--a disease in which deformity results from an arrest, absence,

or perversion of the normal process of enchondral ossification. It is

decidedly an intrauterine affection, and the great majority of fetuses

die in utero. Thomson reports three living cases of achondroplasia. The

first was a child five months of age, of pale complexion, bright and

intelligent, its head measuring 23 inches in length. There was a narrow

thorax showing the distinct beads of rickets; the upper and lower limbs

were very short, but improved under antirachitic treatment. The child

died of pneumonia. The other two cases were in adults, one thirty-nine

and the other thirty-six. The men were the same height, 49 inches, and

resembled each other in all particulars. They both enjoyed good

health, and, though somewhat dwarfed, were of considerable

intelligence. Neither had married. Both the upper and; lower limbs

showed exaggerations of the normal curves; the hands and feet were

broad and short; the gait of both of these little men was waddling, the

hunk swaying when they attempted to make any rapid progress.

Osteitis deformans is a hyperplasia of bone described by Paget in 1856.

Paget's patient was a gentleman of forty-six who had always enjoyed

good health; without assignable cause he began to be subject to aching

pains in the thighs and legs. The bones of the left leg began to

increase in size, and a year or two later the left femur; also enlarged

considerably. During a period of twenty years these changes were

followed by a growth of other bones. The spine became firm and; rigid,

the head increased 5 1/4 inches in circumference. The bones of the face

were not affected. When standing, the patient had a peculiar bowed

condition of the legs, with marked flexure at the knees. He finally

died of osteosarcoma, originating in the left radius, Paget collected

eight cases, five of whom died of malignant disease. The postmortem of

Paget's case showed extreme thickening in the bones affected, the femur

and cranium particularly showing osteoclerosis. Several cases have been

recorded in this country; according to Warren, Thieberge analyzed 43

cases; 21 were men, 22 women; the disease appeared usually after forty.

Acromegaly is distinguished from osteitis deformans in that it is

limited to hypertrophy of the hands, feet, and face, and it usually

begins earlier. In gigantism the so-called "giant growth of bones" is

often congenital in character, and is unaccompanied by inflammatory

symptoms.

The deformities of the articulations may be congenital but in most

cases are acquired. When these are of extreme degree, locomotion is

effected in most curious ways. Ankylosis at unnatural angles and even

complete reversion of the joints has been noticed. Pare gives a case of

reversion, and of crooked hands and feet; and Barlow speaks of a child

of two and three-quarter years with kyphosis, but mobility of the

lumbar region, which walked on its elbows and knees. The pathology of

this deformity is obscure, but there might have been malposition in

utero. Wilson presented a similar case before the Clinical Society of

London, in 1888. The "Camel-boy," exhibited some years ago throughout

the United States, had reversion of the joints, which resembled those

of quadrupeds. He walked on all fours, the mode of progression

resembling that of a camel.

Figure 216 represents Orloff, "the transparent man," an exhibitionist,

showing curious deformity of the long bones and atrophy of the

extremities. He derived his name from the remarkable transparency of

his deformed members to electric light, due to porosity of the bones

and deficiency of the overlying tissues.

Figure 217, taken from Hutchinson's "Archives of Surgery," represents

an extreme case of deformity of the knee-joints in a boy of seven, the

result of severe osteoarthritis. The knees and elbows were completely

ankylosed.

Infantile spinal paralysis is often the cause of distressing

deformities, forbidding locomotion in the ordinary manner. In a paper

on the surgical and mechanical treatment of such deformities Willard

mentions a boy of fourteen, the victim of infantile paralysis, who at

the age of eleven had never walked, but dragged his legs along. His

legs were greatly twisted, and there was flexion at right angles at the

hips and knees. There was equinovarus in the left foot and equinovalgus

in the right. By an operation of subcutaneous section at the hips,

knees, and feet, with application of plaster-of-Paris and extension,

this hopeless cripple walked with crutches in two months, and with an

apparatus consisting of elastic straps over the quadriceps femoris,

peroneals, and weakened muscles, the valgus-foot being supported

beneath the sole. In six months he was walking long distances; in one

year he moved speedily on crutches. Willard also mentions another case

of a girl of eleven who was totally unable to support the body in the

erect position, but could move on all fours, as shown in figure 219.

There was equinovarus in the right foot and valgus in the left. The

left hip was greatly distorted, not only in the direction of flexion,

but there was also twisting of the femoral neck, simulating

dislocation. This patient was also operated on in the same manner as

the preceding one.

Relative to anomalous increase or hypertrophy of the bones of the

extremities, Fischer shows that an increase in the length of bone may

follow slight injuries. He mentions a boy of twelve, who was run over

by a wagon and suffered a contusion of the bones of the right leg. In

the course of a year this leg became 4 1/2 cm. longer than the other,

and the bones were also much thicker than in the other. Fischer also

reports several cases of abnormal growth of bone following necrosis. A

case of shortening 3 3/4 cm., after a fracture, was reduced to one cm.

by compensatory growth. Elongation of the bone is also mentioned as the

result of the inflammation of the joint. Warren also quotes Taylor's

case of a lady who fell, injuring, but not fracturing, the thigh.

Gradual enlargement, with an outward curving of the bone, afterward

took place.

CHAPTER XII.

Date: 2014-12-29; view: 674