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: 663
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