UNIVERSITY OF CALIFORNIA
AT LOS ANGELES
PHYSICAL RECONSTRUCTION
AND ORTHOPEDICS
4 4 7 3 9
PHYSICAL RECONSTRUCTION
AND ORTHOPEDICS
By
HARRY EATON STEWART, M.D.
CAPTAIN MEDICAL CORPS, U.S. ARMY, DIVISION OF ORTHOPEDICS ; ASSISTANT DIREC-
TOR, SECTION OF PHYSIOTHERAPY, SURGEON GENERAl'sOFFICE; INSTRUCTOR
IN MEDICAL AND ORTHOPEDIC GYMNASTICS AND MASSAGE, NEW HAVEN
NORMAL SCHOOL OF gymnastics; ATTENDING SURGEON, NEW HAVEN
ORTHOPEDIC dispensary; FORMERLY INSTRUCTOR IN CORRECTIVE
GYMNASTICS, TEACHERS COLLEGE, COLUMBIA UNIVERSITY.
Authorized for Publication by the
Surgeon General of the U. S. Army
67 ORIGINAL ILLUSTRATIONS
AND 2 DIAGRAMS ^
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lOEHK
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NEW YORK
PAUL B. HOEBER
1920
3^7'>f
Copyright, 1920,
Bt PAUL B. HOEBER
Published Janvary, 19S0
'*<*<* <. '*ti*i
Printed in the United States of Ameriea
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PKEFACE
Physical reconstruction is the watchword of the hour
and yet the picture brought to mind by this phrase is but
a small part of a greater problem, the physical recon-
struction of the race. That there is need for such recon-
struction among us is evident from any study of the re-
jection from service for physical disability which the
draft examinations brought forth. We have become a
city-dwelling nation, and are subject to the innumerable
deleterious influences which follow in the wake of city life
and intense industrial competition. The meager begin-
nings of playground and physical education appropria-
tions and infant welfare movements have as yet in no
way compensated the child for his rapid loss of outdoor
life and freedom. The physician must be deeply con-
cerned with every effort to improve child hygiene. He
is specifically concerned with the problem of prevention
and cure of remedial physical defects. In this book con-
crete directions are given regarding -spinal curvature,
congenital defects, rickets and other orthopedic condi-
tions. The question of competitive athletics and its rela-
tion to health in youth of both boys and girls is considered
and certain definite rules for safeguards are laid down.
In the reconstruction of the wounded soldier, in which
we and our allies are now engaged, much that is new and
of great value has been learned. The new orthopedic
vi PREFACE
principles, appliances, and methods of treatment which
have been evolved have been thoroughly tried out under
exceptional conditions as regards amount of material,
length of observation, and unlimited resources.
The application of the successful methods evolved in
the treatment of war injuries to the treatment of indus-
trial accidents is of the utmost importance to the general
surgeon. Physiotherapy and vocational therapy have,
by proper application and coordination, achieved such
wonderful results that it is inconceivable that they can
have other than a very prominent place in the general
hospital in the future. Every physician and surgeon
should be familiar with the indications for the various
types of treatment, and their effects on the local and
general condition of the patient, his morale, and his re-
turn to his former or new occupation. When one consid-
ers that the number of our wounded was approximately
two hundred thousand, the importance of the viewpoint
just mentioned is seen when we remember that we have in
this country about seven hundred thousand industrial
accidents yearly.
The author's experience in teaching and supervisin.g
reconstruction aides in physiotherapy has convinced him
that a condensed manual, giving the directions for the
various types of treatment as well as the theoretical con-
siderations, would be of great assistance to them in the
work in which they are now engaged. Since vocational
reconstruction is being so largely applied for definite
therapeutic indications, it is of the greatest importance
that the workers in this corps understand the viewpoint
PREFACE vii
and treatment given in physiotherapy, which leads up to
their work. The theory and treatment of congenital and
functional defects other than those following war injuries
should be useful to aides who plan to continue the same
type of work in civil life.
In the teaching of normal-school students of physical
education it has also been evident that they need, for
their work in orthopedic and medical gynmastics, definite
exercise programs for such conditions as faulty posture,
spinal curvature, infantile paralysis, flat foot, etc.
It has been the author's object to present in condensed
form the main principles of orthopedics in the treatment
of the defects of childhood, war injuries, and industrial
accidents, laying stress upon the treatment by massage,
exercise, and other types of physiotherapy. It should,
therefore, be of value to the physician, reconstruction
aide, physical director, and orthopedic assistant, not only
in their better understanding of the work, but in empha-
sizing the vital importance of this so long neglected field.
The author wishes to acknowledge the valuable aid
given him by Miss Helen S. Willard, B.A., his chief
Eeconstruction Aide in Physiotherapy, and Captain G.
W. Ramaker, Vocational Therapy Officer of the U. S. A.
Base Hospital, Camp Meade, Maryland, in the collection
of data for this book.
H. E. S.
New Haven, Conn.
Sept. 1, 1919
CONTENTS
PART I
PHYSICAL RECONSTRUCTION
CHAFTBR PAOB
I Exercise 1
Relation of Bodily Health to Muscular Health. Nerve
Strain of Modem Work. Necessity for Physical Train-
ing in Youth. Athletic Problems. Heart Strain.
Safeguards for Boys and Girls in Athletics. Proper
Exercise for Various Ages. Therapeutic Exercises.
Physiology and Pathology of Muscle Tissue. Exercises
for Stiff Joints. Setting-up Exercise.
II Baking. Hydrotherapy. Electrotherapy . . 27
Physiolo^cal Changes by Baking. Passive Hyperemia,
Hydrotherapy Definition, History. Properties of
Water. Physiological Effect on the Various Tissues and
on Body Temperature. Technique of the Various Baths.
Electrotherapy Types of Ciirrent, Uses. Ionic Medica-
tion. Alpine Sun Lamp.
III Massage 46
Definition. History. Tsrpes of Movement. General Con-
siderations. Effect on Different Tissues. Mechanics of
the Cardinal Movements. Therapeutic Uses and Con-
traindications. Treatment of Limb Stumps.
IV Vocational Therapy 7ft
Objects Therapeutic, Economic, Occupational Interest,
Morale. Co-operation with Physiotherapy, with Federal
Board. Types Bedside, Shop, Classroom, Field.
Scope Application in General Hospitals, Simple Equip-
ment, Relation to Industrial Accidents.
X CONTENTS
PART II
ORTHOPEDICS
CHAPTER PAOB
V Congenital Defects 91
\^lub Foot Types, Treatment. Hip Dislocation. Hibb's
"Table. Rickets Cause, Diagnosis, Treatment. Coxa
Vara Pathology, Treatment. Spastic Paralysis
Causes, Treatment.
VI Infantile Paralysis 97
Pathology. Treatment in Active Stage. After-treatment.
Exercises for Paralyzed Arm and Leg.
VII The Spine Diseases and Injuries 106
Anatomy. Tuberculosis Diagnosis, Symptoms, Treat-
ment. Traumatic Injuries, Strain and Sprain. Sacro-
iliac Strapping. Treatment of Bruises. Fractures and
Dislocations Diagnosis, Treatment. Penetrating
Wounds.
VIII Curvature of the Spine HI
Kyphosis Tjrpes, Causes, Symptoms, Treatment,
Program of Exercises. Lordosis Occurrence, Causes,
Sequelae, Program of Exercises. Scoliosis Pathology,
Rotation, Occurrence, Classifications, Causes, Treat-
ment. Exercise Programs for the Various Types.
IX Joint Injuries and Arthritis 135
General Anatomy. Traiunatic Lesions. Strain and
Sprain Treatment. Arthritis. Toxic Arthritis. Ar-
thritis Deformans, or Rheumatoid Arthritis Diagnosis,
Treatment. Acute Rheumatic Arthritis. Tuberculous
Arthritis Diagnosis, Treatment. Gonorrheal Ar-
thritis Diagnosis, Treatment. Syphilitic Arthritis
Diagnosis, Treatment.
X Diseases of Bones 146
Periostitis Pathology, Diagnosis, Treatment. Osteitis.
OsteomyeUtis Diagnosis, Treatment. Osteomalacia
Diagnosis, Treatment.
CONTENTS xi
CHAPTEB PAGB
XI Fractures and Dislocations. The Upper Ex-
tremity 152
The Clavicle. Sternoclavicular Dislocations. Fractures.
Acromioclavicular Dislocations. The Scapula. Fractures.
Shoulder Joint, Surgical Anatomy. Types of Dis-
location. Fractures of the Humerus. Anatomica.' Neck.
Shaft. Supracondyloid. Epicondyloid. Epitrochlear.
Fractures. Involving the Elbow. Types. Olecranon
Dislocations of tho Elbow. Types. Myositis Ossificans,
Traumatica. Dislocations of the Radial Head. Ankylosis
of the Elbow. Fracture of the Head of the Radius.
Fractures of the Shaft. Fractures of the Radius and
Ulna. The Wrist. CoUes Fracture, Dislocations. The
Hand Fractures, Dislocations.
XII Fractures and Dislocations (Continued). The
Lower Extremity 183
The Pelvis. Types of Fracture. Dislocation of the Sym-
physis. Dislocations of the Hip Joint. Fractures of the
Femur. Upper End. Shaft. Lower End. Fractures and
Dislocations of the Patella. Dislocation of the Knee.
Fracture and Dislocation of the Semilunar Cartilages.
Rupture of the Crucial Ligament. Fractures of the
Upper End of the Tibia and Fibula. Fractures of the
Shaft. Lower End. Pott's Fracture. Dislocations of the
Ankle. Fractures of the Metatarsus.
XIII Foot Strain . y. 205
y
The Main Arch. Types of Flat Foot Causes, Diagnosis,
Treatment, Strapping, Plates, Exercise, Programs. The
Anterior Arch. Metatarsalgia Causes, Diagnosis, Exer-
cises. Foot Ailments in the Army. Foot Strain-
Literature, Military Viewpoint, Classification, Anatomy,
Methods of Examination. Diagnosis and Treatment of
Weak Foot. Flaccid Flat Foot. Rigid Foot. Acute and
Chronic Foot Strain. Hammer Toe. Corrective Shoe
Appliances. Minor Foot Ailments. Synovitis. Blisters.
Abrasions. Tissues. Overriding Toes. Corns. Callosi-
ties. Warts. Sweating Feet. Chilblains. Trench Foot.
Shoe Fitting. Prescriptions.
xii CONTENTS
CHAFTKR PAOB
XIV Braces and Casts 229
Braces for Arch, Club Feet, Knee, Bowleg, Knock Knee.
Infantile Leg. Spine. Casta. Care and Preparation of
Plaster Technique.
Glossart .... 235
Index 237
LIST OF ILLUSTRATIONS
no. PAGE
1 Entire Scapula, Except Part of Acromion, Missing . . 5
2 Gain from Complete Disability in Six Weeks of Physio-
therapy 5
3 Severe Shrapnel Wound of Left Shoulder with Com-
pound Comminuted Fracture of 6th and 7th Ribs . 11
4 Slanting Ladder, Use of Body Weight to Secure Passive
Flexion of Stiff Knee Joint 15
5 Suspension Used to Stretch Adhesive Bands in Right
Elbow 15
6 Chipping of Humeral Head and Extensive Wound of
Shoulder 21
7 Abduction Assisted Largely by Scapular Rotation Well
Controlled 21
8 Hyi)erextension Limited by Scar Tissue and Adhesions . 21
9 Muscle Contraction Test for Nerve Injury. Faradic
Battery and Generator 25
10 Baking. Electric Light Bath of Knee ..... 26
11 Diathermy. Electrical Heat Penetration for Deep
Hyperaemia 26
11a Multiplex Sinusoidal Machine 31
lib High Frequency Machine 31
lie Alpine Sun Lamp, Ultra Violet Ray 32
12 Electro-Motor Points, Upper Extremity 37
13 Electro-Motor Points, Lower Extremity 38
14 Electro-Motor Points, Trunk 41
15 Massage. Effleurage or Stroking of Forearm ... 47
16 Massage. Petrissage or Kneading of Calf .... 47
17 Passive Stretching of a Flexion Contracture at the Elbow 61
18 Massage. Friction Here Used to Loosen Scar Tissue . 51
19 Massage. Tapotement or Hacking of Muscle ... 55
xiii
xiv LIST OF ILLUSTRATIONS
FIG. PAGE
20 Posterior Half Cast to Prevent Foot Drop .... 55
21 High Explosive Wound of Left Hand 59
22 Loss of 3d and 4th Metacarpals 59
23 Basket-Making 77
24 Telegraphy 77
25 Clay Modeling 78
26 Chair Caning 78
27 Wood Toy Making 78
28 Teaching the Beginnings of Mechanical Principles . . 83
29 Adjustable Foot Appliances 87
30 Musical Knowledge Reapplied to an Instrument the
Man's Disability Will Allow Him to Play .... 88
31 Automobile Repair Shop 88
32 Woodworking 88
33 Carriage Which Reduces Friction and Allows on a
Smooth Surface a Wide Range of Movement with Slight
Effort 95
34 Wire Cockup Splint for Wrist Drop, Light in Weight,
and Requires no Bandaging 95
35 Self -Correction for Right Dorsal Left Lumbar Scoliosis . 125
36 Spring Sitting-Position in Right Dorsal Left Lumbar
Scoliosis 125
37 Osteomyelitis of Lower End of Tibia and Osteo- Arthritis
of Ankle Joint 147
38 External Condyle of Femur Shot Away. Osteomyelitis
and Ankylosis 147
39 Cabot Posterior Leg Splint 155
40 Airplane Splint with Elbow Joint 155
41 Abduction Splint for Shoulder 159
42 Humeral Extension Splint 159
43 Comminuted Gunshot Fracture of Glenoid and Humerus
at Surgical Neck, with Large Amount of Bone De-
struction 163
44 Humeral Neck and Head Fractured, Beginning Bony
Union. Shrapnel in the Head 163
45 Extensive Shrapnel Wound of Right Arm with Com-
pound Conuninuted Fracture of Humerus . . . 171
LIST OF ILLUSTRATIONS
XV
FIQ. PAQB
46 Machine-Gun Bullet Through Condyles of the Left
Humerus 171
47 Old Infected Gunshot Wound of Upper End of Right
Radius and Ulna Involving Elbow Joint .... 171
48 \ Compound Comminuted Fracture, Oblique of Radius
49 J and Transverse of Ulna with Over-Riding of Frag-
ments 175
50 Loss of Bone in the 2d and 3d Metacarpals with New
Joint Formation 175
51 Loss of Portion of 2d and 3d Metacarpal .... 175
52 Extension Applied to Fracture of Both Bones of the
Forearm 179
53 Bradford Frame with Extension Applied to Leg for
Fracture of Femur with Shortening 179
54 Caliper Walking Splint 189
55 High Explosive Shell Wound of the Hip, Sustained July
14, 1918 189
56 Fracture of Tibia, Compound Comminuted, with Large
Loss of Bone Substance 199
57 Fall fom Horse Causing Fracture Through Head of
Astragalus 199
58 Compound Comminuted Fracture of Tibia and Fibula . 199
59 Exercise 11. Walking Forward on Outer Edge . . . 207
60 Exercise III. Rising on Toes, Toeing In .... 207
61 Exercise IV. Walking Forward on Outer Edge, Toeing
In 207
62 Exercise V. Ground Gripper Walk 207
63 The Hammock Arch Plate 213
64 The Hammock Arch Applied 213
PHYSICAL RECONSTRUCTION
AND ORTHOPEDICS
PART I
PHYSICAL RECONSTRUCTION
Chapter I
EXERCISE
The health of the body is, in the last analysis, abso-
lutely dependent upon the health and tone of the muscular
system. The condition of the heart muscle and the non-
striated fibers of the blood vessels and gastrointestinal
tract, are profoundly influenced by the tone of the skeletal
muscles. Many glands are stimulated both directly and
indirectly as a result of proper muscular activity. These
statements are obvious, almost trite, and yet they are
constantly overlooked. The physician often treats first
by drugs, then with attention to diet and sleep, and lastly,
if at all, by exercise.
In modem business and industrial life the premium is
placed upon nervous activity and very fine muscular co-
ordination. This type of work is exhausting without any
corresponding upbuilding of vigor. Physical work in-
volving larger groups of muscles, while equally tiring,
2 PHYSICAL EECONSTRUCTION
tends to build up both the muscular structure and the
general health. Years ago even the skilled artisan used
to move about the plant selecting his materials, perform-
ing quite varied operations upon them, and perhaps car-
ried the finished product to the shipping room. There-
fore he was compelled to take a certain amount of general
exercise. Modem efficiency has ruled that cheap labor
shall bring in these materials, perform the easier opera-
tions, and remove the finished product, while the arti-
san's entire time is occupied in repeating, hundreds of
times daily, some one or two specialized movements,
which usually require prolonged, acute attention and
delicate coordination. Thus only certain small muscle
groups are apt to be used.
The same tendency is seen in modem business and
professional life, where present appliances make it pos-
sible to conduct a whole day's business from the office
chair.
The many occupations which require standing for
hours subject those muscles which maintain the upright
posture to strain, rather than exercise. The work of
the heart, unassisted by alternating muscular compres-
sion and relaxation applied to the veins, is greatly in-
creased, and the muscles and ligaments of the foot are
subject to a distinct strain. It must be clear, then, since
most occupations resemble more or less one or the other
of the three types of occupations mentioned, that the
average person under modern conditions does not have
sufficient exercise for the maintenance of the best effi-
ciency. That women, as a class, with the added handicap
EXERCISE 3
of dress and social restrictions, take far too little exercise
every one will recognize.
There is no escape from the tendency of modem life
further and further to restrict normal exercise and in-
crease the strain of professional and industrial life. I
take it to be of the utmost importance that we should
see to it that every child and youth be given the oppor-
tunity to lay by a surplus in his bank account of health,
for these certain and severe strains which modem life
makes it impossible for him to avoid. Since we have
become a city-dwelling nation, with extremely limited
play space, the youth is not so apt to be endowed with a
vigorous muscular system at the beginning of his life
work as were his father and grandfather. Until we have
multiplied our playground, recreational center, and
school gymnasium appropriations many times over, wo
shall suffer as a nation from this lack of muscular vigor.
That every child should have a thorough physical
training is recognized by every physician. There are,
however, problems closely associated with modem ath-
letics which relate to possible overstrain of heart and
disturbed blood pressure, which are not universally un-
derstood. During my experience in the physical educa-
tion of both girls and boys, I was struck with the lack
of definite knowledge in the profession of the results of
vigorous athletic training on the heart and blood pres-
sure.
The heart becomes stronger, the cardiovascular ad-
justment more perfect, and the blood pressure is not
raised, by athletic training. Safeguards that the physi-
4 PHYSICAL RECONSTRUCTION
cian should insist "upon in all athletic sports in both boys
and girls are, first, preliminary medical examination;
second, constant trained supervision; third, play only
when in perfect health. I want to emphasize the fact that
the delicate child can be built up, and should be encour-
aged to exercise when carefully watched; that the heart
is a muscle, and as such can be increased in both size
and strength when carefully kept from strain.
The physician's advice is often sought by parents in
regard to the proper amount of physical training that
should be taken by the normal child. Such advice can
hardly be given without a knowledge of the circumstances
surrounding the exercise, which may have a marked effect
upon the benefits derived. The number and length of the
periods per week, their time relation to meals and fa-
tigue, temperature, ventilation, apparatus used, and the
way the schedule is graded, all are important.
Nearly every normal boy goes in for athletics. His
enthusiasm, and that of the coach who must produce a
winning team, make it very easy to overstep the limits of
safety. We must remember that the boy, as a rule, id
carrying a heavy burden of growth, development, study,
and extra-curriculum activity.
It must be constantly kept in mind that the growth
of the heart and larger blood vessels is from one to two
years behind the rest of the body, during adolescence.
For this reason heart strain is more common than gen-
erally realized. Such games as basketball, football, and
hockey should be broken up by frequent rest periods. I
believe no secondary-school boy should run farther than
fe*
o
J
H .
H
\. .'
^
EXERCISE 7
the 220-yard dash. Cross-country running and distance
runs should be reserved for college days. The marathon,
or even modified marathon run, is fraught with the grav-
est danger to heart and kidneys, as shown by the work of
W. L. Savage of New York.
No boy should be allowed to participate in more than
one major sport at one time, and intervals between train-
irig'seasons are desirable. Many breakdowns occur from
indulging in athletics when suffering from slight illness,
such as tonsillitis, or attempting to return to sport too
soon after the cardiac muscle has been impaired by the
toxins of disease.
The recent rapid growth of girls' athletics has brought
us face to face with the same problems in regard to heart
strain or overindulgence that we have found in athletic
training for boys. My experimental study, * * The Effect
on the Heart Rate and Blood Pressure of Vigorous Ath-
letics in Girls,*' American Physical Education Review,
1914, showed that even such violent sports as basketball
and track athletics were extremely beneficial when prop-
erly safeguarded.
In regard to girls' athletics, the work of Dr. Clelia D.
Mosher of Stanford University, and others, has modified
greatly our ideas in regard to the proper relation between
exercise and menstruation. It seems to be the unanimous
belief that we may safely be much more liberal in our
exercise allowance at that time; that marching tactics,
calisthenics, and club swinging have a distinctly benefi-
cial effect in lessening pain and disability. This is un-
doubtedly the result of a redistribution of the circulation
\
8 PHYSICAL RECONSTRUCTION
and improved mental attitude. In fact, it is emphasized
that the psychical attitude is of great importance, and
that the girl should be discouraged from thinking of this
perfectly normal function in terms of illness. Among col-
lege women Dr. Mosher and others have succeeded in
lessening the pain and disability to a very marked degree
by exercise and treatment, the fundamental part of such
a program being deep abdominal breathing with jin-
creased use of the diaphragm by training. This may be
done with the patient lying supine and her effort directed
toward raising and lowering, to as great an extent as
possible, a moderately heavy book placed upon the abdo-
men. The more violent types of athletics, including jump-
ing and running, should be interdicted for at least three
days and longer, when necessary, in any individual case.
I am convinced that we are only at the beginning of our
knowledge of the possibilities of woman's physical devel-
opment. Already in such a sport as track athletics, in
spite of their very recent development and meager oppor-
tunities, girls are making records in the different events,
which range from two-thirds to three-quarters of those
records made by our Olympic champion athletes. Those
invaluable traits of character, loyalty, unselfishness, self-
control, and the team-work ideal, are developed by ath-
letics as in no other way. I have not seen, in my ex-
perience, the slightest tendency for athletics, developed
by coaches with the proper ideals, to make girls in any
way less womanly.
The sudden secession from regular exercise, which
usually comes at the end of school and college life, is
EXERCISE 9
something which should not he allowed to occur. From
the vigorous games of youth the transition should he
made through the gymnasium, volley ball, and tennis to
such sports as hiking and golf, which can be followed
throughout life. This principle should be applied to both
sexes. In general, it is well for the physician to keep in
mind that, after a great deal of painstaking study, physi-
cal educators, as a rule, have come to the following con-
clusions: 1. That exercises of speed, those exercises in
which a certain distance is covered in the shortest time,
are not suited in their severe forms except to persons
in good condition from eighteen to thirty-five. 2. That
exercises of strength, which require all of one's energy to
perform for instance, weight throwing, weight lifting,
and apparatus work are suited to the ages of twenty
to thirty-five. 3. That exercises of endurance, which con-
stitute many and rhythmical repetitions of easy move-
ments, such as distance running, walking, bicycle riding,
etc., are suited to any age up to fifty (they are self-
limited in childhood), the only exception being the period
of accelerated growth, as regards games and distance
running, before mentioned. 4. That exercises of skill
such as golf, archery, quoits, etc., are suitable through
all one's active life, and are invaluable, especially after
fifty.
Many games, such as tennis, may partake of several
or all of these types, and in advising in regard to them
one should be guided by the other general principles
already outlined.
I have appended a simple drill of ''setting-up exer-
10 PHYSICAL RECONSTRUCTION
cises" which will make for general development, and a
set of exercises on the chest weights, which may be used
in the same way, but which is mainly intended to exercise
fully both actively and passively each possible joint.
These chest-weight movements will greatly assist in
the return of function after the disability following
fracture, dislocation, or arthritis.
Therapeutic Exercise. Turning from the value of ex-
ercise, as a means of upbuilding and retaining general
health, to exercise as a purely therapeutic measure, there
are several things to be considered. In the treatment of
patients by exercise much more enters into the problem
than the conditions relating to the involved group or
groups of muscles. The inheritance of the patient, the
environment in which he has been and that in which he
must remain during the treatment, and the special eifect
of his stage of development must all be carefully con-
sidered. The importance of the last fact has been too
often overlooked. For example, as E. H. Arnold of New
Haven has emphasized, in the giving of corrective exer-
cises to children during accelerated growth, more harm
than good is often done by overload of work or by the
superimposing of a strenuous exercise regime on the al-
ready too severe strain of growth, development, and
school life, which the child is carrying. Furthermore, we
must expect a far different reaction to exercise treat-
ment on the part of a patient who has left the ''elastic
age" of youth and entered the "connective tissue age('
of middle and late life. It is also the physiological and
not the chronological age which it is essential to keep in
Fig. 3. Severe Shrapnel Wound of Left Shoulder with Compound Com-
minuted Fracture of 6th and 7th Ribs.
X-Ray shows entire body of scapula missing, glenoid, coracoid and acromion
processes intact. Piercing fracture of ribs. Movements at shoulder limited to
40 of flexion and 20 of abduction. After four weeks of massage and exercise
active flexion to 80, abduction to 50.
EXEKGISE 13
mind, as has been pointed out by C. W. Crampton of
Battle Creek. We have found in the New Haven Ortho-
pedic Dispensary many cases of children who had to be
taken from home surroundings for the simple purpose
of supplying them for a sufficient period of time with
adequate nourishment before the special treatment out-
lined could be expected to achieve the desired result.
There are four main types of exercise used: (a) that
done entirely by the operator (passive) ; (b) that done
by the patient assisted in varying degrees by the opera-
tor (assistive) ; (c) that done wholly by the patient
(active) ; (d) that done by the patient opposed by the
operator ^weights, friction, or the opposing group of
muscles (resistive). The muscular contraction in the last
type has been further divided into three varieties, ac-
cording to the direction of the movement of the muscle 's
insertion in relation to its origin. For instance, in the
contraction of the biceps when opposed by the action of
the triceps (self -resistive exercise), the former may
slowly overcome the pull of the latter and its origin and
insertion be brought nearer together concentric contrac-
tion; or the power of both may be equal, so that the
distance between the origin and insertion remains un-
changed static contraction; or the pull of the triceps
may be greater, bringing further apart the points of ori-
gin and insertion eccentric contraction.
As we proceed in the development of the muscular sys-
tem certain changes in structure take place. With in-
creased bulk and tone developed by exercise there is a
tendency for the entire body of the muscle to shorten,
14 PHYSICAL KEGONSTRUCTION
bringing its points of origin and insertion nearer to-
gether. We make use of this property of well-developed
muscle to shorten in the treatment of many orthopedic
conditions for instance, in a round-shouldered child we
exercise particularly the muscles of the upper back, there-
by retracting the shoulders. It might here be noted, as
will be emphasized later, that disuse, such as would fol-
low the application of a shoulder brace in this same
group, has ultimately the opposite effect, namely, to
stretch out and weaken the affected muscles and to in-
crease the slump. This shortening of the stronger mus-
cles is also seen where there is a lack of balance in the
power between two muscles or muscle groups having an-
tagonistic function as, for instance, following partial
paralysis. The less affected tends to shorten at the ex-
pense of the more affected muscle or muscle groups.
Muscles, then, are elastic, and will shorten when given
the opportunity. If this condition remains long enough,
real structural shortening ensues. For example, the
wearing of high heels for many years has a marked
tendency to produce structural shortening of the calf
muscle. This tendency to contraction is undoubtedly
due to the property of muscle called tone, or tonus.
Muscle tone is the result of a slight constant contraction
of many of the fibers of any healthy muscle. Tone is
increased in vigorous bodily health and well-developed
muscle and in response to mental stimulus. It is de-
creased during mental depression, bodily weakness, and
sleep, and practically lost under complete anesthesia or
other complete loss of consciousness.
EXERCISE 17
Fatigue is a sluggish or subnormal response of a mus-
cle to its stimulus. This may be due to either a weak-
ening of the stimulus itself following injury or weakness
of the neurone, or to a deadening of the sensitivity of the
end-plate of the nerve in the muscle cell by the accumu-
lation of fatigue products. The first fatigue products
are stimulants to muscular activity, and this accounts
for the fact that a muscle works better after a few con-
tractions than at first. That is why we "warm up" a
muscle before severe exertion.
The early onset of fatigue must be carefully watched
whenever the muscle is subnormal. In regard to general
fatigue the point is often overlooked that it is cumulative
in its effect. This means that a little more work done
by a fatigued muscular system calls for the expenditure
of a tremendous amount of nervous energy.
Remedial gymnastic programs for the various ortho-
pedic conditions infantile paralysis, kyphosis, lordosis,
scoliosis, flat feet, etc., are fully given in the sections
where each is discussed.
CHEST WEIGI^T EXERCISES.
The position assumed for active flexion gives passive extension,
and vice versa.
Unless otherwise stated, the use of the shoulder height weights
is indicated.
1. Wrist.
A. Flexion.
Patient stands with back of hand toward weights, arms
extended downward and flexes. (Passive extension.)
18 PHYSICAL EECONSTRUCTION
B. Extension.
Patient stands with palm of hand toward weights, arms ex-
tended downward and extends. (Passive flexion.)
2. Elbow.
A. Flexion.
1. Patient stands facing weights, arms extended forward.
Flex, extend.
2. Overhead weights. Arms extended upward, hands en-
cased in gloves and bound to handles if necessary.
Flex, extend.
B. Extension.
1. Patient stands with back to weights, elbow flexed shoul-
der high and rope over shoulder. Extend, flex.
2. Overhead weights. With arms at side, let weights flex
elbow. Extend, flex.
C. Pronation.
Patient stands affected side toward weights, elbow flexed,
and fixed at side by other hand or by operator. Lower
forearm across body and return.
D. Supination.
Patient stands unaffected side toward weights, elbow
flexed and fixed at side by other hand or by operator.
Draw forearm up and sideward and return.
3. Shoulder.
A. Flexion.
1. Floor or shoulder weights.
a. Patient stands facing weights, arms extended for-
ward, supinated or pronated. Lower arms and
raise.
5. Patient lying supine, head toward weights, arms
extended upward. Lower arms fore downward
to sides and raise.
2. Overhead weights.
Arms extended upward, lower fore downward and
raise.
EXERCISE 19
B. Extension.
1. Floor or shoulder weights.
CL Patient stands with back to weights, arms extended
downward. Raise arms forward and return.
h. Patient lies supine, feet toward weights. Raise
arms fore upward and return.
C. Abduction.
1. Patient stands unaffected side toward weights, affected
arm across body.
a. Abduction in a lateral plane, elbow flexed. Ex-
tend elbow. Keep at shoulder level. Return.
h. Carry straight arm forward and sideward at shoul-
der level. Return.
2. Floor weights.
Patienl lies supine, feet to weights. Raise arm side-
ward, return.
D. Adduction.
1. Patient stands, affected side toward weights, arm ex-
tended, shoulder level. Carry arm forward across
chest, keeping straight or flexing elbow, then ad-
ducting shoulder. Return.
2. Floor weights.
Patient lies supine, head to weights, arm extended
upward. Lower sideward, raise.
3. Overhead weights.
a. From extended arm. Lower and raise.
(1) Carry arm obliquely fore downward.
(2) Carry arm side downward.
(3) Carry arm obliquely back downward.
Combination of adduction and abduction.
Raise arm sideward to shoulder level, carry forward and
return, carry backward and return.
20 PHYSICAL RECONSTRUCTION
4. Trunk.
Resistance to forward, backward, and lateral bending of
the trunk is obtained by fixing the handle of the
weights at given points in relation to the trunk. The
higher the weight is fixed, the greater the resistance
given. The weight may be fixed on abdomen, chest,
head, or arms extended over the head.
5. Thigh. Foot bound to handle by special slipper or loop at-
tached to shoe.
A. Flexion.
1. Floor attachment.
a. Patient supine, feet toward weights, knee flexed or
straight. Flex, extend.
h. Patient lying on side, feet toward weights, knee
flexed or straight. Flex, extend.
c. Patient standing, back to machine. Flex, extend.
B. Extension.
1. Floor attachment.
a. Patient supine, head toward weights, knee flexed
or straight. Extend, flex.
h. Patient lying on side, head toward weights, knee
flexed or straight. Extend, flex.
c. Patient standing, facing weights. Extend, flex.
C. Abduction.
1. Floor attachment.
Patient stands or lies supine, unaffected side toward
weights. Abduct, return.
D. Adduction.
1. Floor attachment.
Patient stands or lies supine, affected side toward
weights. Adduct, return.
E. Rotation.
1. Floor attachment.
Patient lies prone, knee flexed, side toward weights.
(a. Unaffected side for inward rotation, h. Af-
Fig. 6. Chipping of Humeral Head and Extensive Wound of Shoulder.
No active motion at first. Flexion after five weeks of massage and exercises.
Fig. 7. Abduction Assisted Largely by Scapular Rotation well Con-
trolled.
Fig. 8. Hyperextension Limited by Scar Tissue and Adhesions.
EXERCISE 23
fected side for outward.) Rotate by swinging
foot sideward.
6. Knee. Foot bound to handle.
A. Flexion.
1. Floor attachment.
a. Patient stands facing weights. Flex, extend.
b. Patient lies prone, feet toward weights. Flex, ex-
tend.
B. Extension.
1. Floor attachment.
a. Patient stands back to weights, knee flexed. Ex-
tend, flex.
b. Patient lies prone, head toward weights, knee
flexed. Extend, flex.
Setting-up Exercises.
1. a. Arms to thrust raise, thrust forward, return, lower.
b. Arms to thrust raise, thrust sideward, return, lower.
c. Arms to thrust raise, thrust upward, return, lower.
2. Hands on hips.
a. Heels raise, lower.
b. Toes raise, lower.
c. Heels raise, knees deep bend, knees straighten, heels
lower.
3. Hands on hips.
a. Trunk sideward right bend, raise, bend sideward left,
raise.
b. Trunk sideward right turn, return, turn sideward left,
return.
c. Trunk lower forward, raise, bend backward, raise.
4. a-. Arms forward raise, carry sideward, carry forward,
lower.
b. Arms sideward raise, carry forward, carry sideward,
lower.
24 PHYSICAL RECONSTRUCTION
e. Arms forward raise, carry upward, lower forward,
lower downward.
d. Arms sideward raise, carry upward, lower sideward,
lower downward.
5. Hands on hips.
a. Raise right knee, lower.
&. Raise left knee, lower.
c. Raise right knee, extend leg forward, bend knee, lower.
d. Raise left knee, extend leg forward, bend knee, lower.
6. Jump to stride stand, arms raise sideward.
b. Trunk bending, alternating right and left.
h. Trunk turning, alternating right and left,
c. Hands behind head.
Trunk bending alternately forward and backward.
7. Stationary running on toes with high knee raising.
Fig. 10. Baking. Electric Light Bath of Knee.
Fia. 11. Diathermy. Electrical Heat Penetration for Deep Hyper^bmia.
Chapter II
BAKING HYDROTHERAPY ELECTRO-
THERAPY
. BAKING
The result of the treatment of a part of the body by
superheated dry air is to cause a local dilatation of the
skin and subcutaneous capillaries, thereby thinning their
cell, walls and increasing the intercellular spaces. A
greatly increased amount of blood serum with its con-
tained food is thus permitted to pass out and supply the
tissue cells. This, and the increased removal of waste
brought about by the accompanying stimulation of the
lymphatic circulation, are the two essential factors in
shortening the period of tissue repair.
The common means employed to obtain this result are :
First, electric lights with reflectors, such as the thermo-
light; second, the adjustable local electric light bath
(Burdick) ; third, Kellogg 's thermophore; fourth, the
electric light body cabinet ; and fifth, the various types of
ovens heated by gas and alcohol, some of which are quite
inexpensive. For the application of heat to the deeper
tissues, machines for electric heat penetration are used.
The average length of treatment is twenty minutes. In
baking, the part must be well wrapped in a dry towel.
27
28 PHYSICAL RECONSTRUCTION
Watch for scars or anesthetic areas. The heat is given
at 250 to 400 degrees.
Passive Hyperemia. This method of increasing local
blood supply by means of the constriction band placed
proximally to the part, tight enough to shut off the venous
return but not to impede the arterial inflow, is usually re-
ferred to as the Bier treatment. This method should
precede the other types of treatment indicated on the
part and its duration should not exceed ten minutes. It
is a valuable method of obtaining passive hyperemia,
especially in selected cases where means of procuring ac-
tive hyperemia are not available.
HYDKOTHEEAPY
Definition. Hydrotherapy is the application of water
to the surface of or within the body for the relief of
diseased condition.
History. The therapeutic value of this agent was
known to the Egyptians, Chinese, Greeks, Romans and
Arabs. Modem use of water for curative purposes be-
gan in the sixteenth century in Italy, France and Eng-
land, as shown in the writings of Lanzani, Barra, Wesley,
CuUen and Floyer. In the United States Rush, Lockette,
Bell and others have added to our knowledge of this
form of treatment. Among modem writers none have
contributed more than Kellogg of Battle Creek.
At the present time the use of hydrotherapy is being
greatly extended and its value more largely recognized.
While our larger sanitaria and hospitals have expensive
HYDROTHERAPY ELECTROTHERAPY 29
equipments, it is possible to obtain most of the funda-
mental benefits from the various forms of treatment with
very simple apparatus.
Properties. The physical properties of water are all
made use of in our treatment. Its different forms solid,
liquid and gas all have their places. Added value is de-
rived from the ability of the water to hold certain salts
and minerals in solution. Varying degrees of the tem-
perature of the water used, and the force and amount
in which it is applied, each affect the result of the treat-
ment.
Effect. The main desired result is obtained through
the thermal and mechanical effect of the application of
water on the sensory nerve endings in the skin. Re-
flexly, changes are brought about in the circulation and
nervous system.
Circulation, (a) Distribution of the blood. The appli-
cation of hot water brings about a local hyperemia. Cold
water induces vasomotor contraction in the skin and
dilatation in the deeper tissues, followed later by cuta-
neous dilatation.
(b) Composition of the blood. A redistribution of the
blood cells shows a marked increase in the red blood cell
count in the circulation.
(c) Changes in blood pressure. By increasing the skin
elimination of toxins and blood vessel dilatation, we are
able to reduce high blood pressure. Hot and tepid baths
are used. The stimulating effect of cold baths will im-
prove capillary tone and raise the pressure when below
normal.
30 PHYSICAL RECONSTRUCTION
Respiration. A tonic bath will induce deep breathing
and raise the general body tone.
Nervous SysteWr. (a) Stimulation of the nervous sys-
tem is secured by the various tonic baths. Vigorous rub-
bing and massage are helps in securing this result. Often
a hot bath will act as a stimulant.
(b) Sedative effect on the nervous system is obtained
by a long continued tepid bath.
Muscular System. The removal of local and the les-
sening of systemic fatigue is possible by means of the
tonic bath.
Skin. The direct effect of water applied to the skin
is that of a mechanical irritant. This action may be in-
creased by the use of salt, etc. The circulatory effect has
been described. The removal of waste matter is best ac-
complished by warm water. Cold water stimulates, closes
the pores and protects against cold.
Body Temperature. Cold water is now used freely
to lower body temperature in typhoid, heat stroke, etc.
It may safely be repeated several times daily if neces-
sary. It is a good general rule preceding every bath to
heat the body. Methods in common use are the blanket
pack, electric cabinet, electric cradle, or exercise.
Electric Cradle or Cabinet Bath. In using the cradle
(which is a frame wired with lights fitting over the pa-
tient in bed) or the cabinet (lined with lights in which
the patient sits) cover the head with ice cap or cold wet
towel. Take the temperature often and discontinue the
treatment when the temperature has reached 100 degrees
or the patient perspires freely. Indications All forms
Fig. 11a. Multiplex Sinusoidal Machine.
Fig. lib. High Fpequency Machine.
Fig. 11c. Alpine Sun Lamp, Ultra Violet Ray.
HYDROTHERAPY ELECTROTHERAPY 33
of intoxication, gout, nephritis and the relief of internal
congestion.
Wet Pack. Wrap the patient in a wet sheet and then
several blankets. Be careful not to have the surfaces of
the body touching. Cold packs stimulate, warm ones
soothe. Treatment should average about an hour or to
desired physiological effect, and be followed by rest.
Evaporation Pack. This type of tonic treatment is
given for fifteen or twenty minutes. Cover patient with
wet sheet and one loose blanket. It may be given locally
as a compress, or as a body pack. It is well to use a head
compress also.
Neptune Girdle. Two sizes of binder 15" by 60'' and
18" by 72" will serve. Wrap the patient's abdomen in
the wet linen binder and cover with dry flannel one slight-
ly larger, being careful to exclude the air. Indications
Nervousness, insomnia, nausea and digestive dis-
turbances.
Abdominal Coil. Put on the linen binder, then the coil,
then flannel binder. Run water through coil 120 degrees
for 15 minutes; remain the rest of the hour.
Local compresses are used to relieve hyperemia.
Simple Tonic Bath. Sponge bath; apply water with
slight friction with hand or cloth.
Half Bath. Tub half full of water at 85 degrees lower
to 70 degrees or 65 degrees. Pour water over the patient
and rub with the hand; sit three to five minutes, then
apply the cooler water.
Drip Sheet. Stand in a tub of hot water. Hold the
sheet so that one-third is in one hand and two-thirds in
34 PHYSICAL RECONSTRUCTION
the other. Dip in water; lift out and wrap around pa-
tient' and pour on more water duration three to five
minutes.
Sitz Bath. Sit in sitz bath, place feet in bath tub.
Apply water 80 degrees to 60 degrees. Keep rubbing the
skin, the patient rubbing the thighs and the operator rub-
bing the shoulders and back. For bladder disturbances,
pelvic congestion.
Use hot water for spasms, colic or chronic intestinal
conditions. The body surface should be flushed with
heat, followed by a cold shower to get a good reaction or
the patient put to bed with the room at an even tempera-
ture till the vessels regain their equilibrium. For con-
ditions following shell shock, irritable heart, hallucina-
tions, fearful dreams, and neurasthenia, the bath at 94
degrees is kept up for an hour or more.
Douche. Treatment begins with water 90 degrees, ris-
ing to 115 degrees and ending with 60 degrees. Continue
for two minutes.
Scottish Douche. Two jets, one 100 degrees, the other
60 degrees, applied alternately by a lateral sweep of the
nozzle up and down the spine.
Whirl Bath. For sensitive stumps or masses of scar
tissue, treatment by whirling water at 95-110 degrees,
mixed or unmixed with air, leads to a very marked reduc-
tion of sensitiveness and to active hyperemia, and is an
invaluable means of the preparation of the part for
massage or exercise.
HYDROTHERAPY ELECTROTHERAPY 35
ELECTEOTHEBAPY
This important type of treatment is being rapidly de-
veloped and the scope of its usefulness greatly enlarged.
It is essential that the student of electrotherapeutics have
the elemental facts outlined for him in the simplest pos-
sible form.
The therapeutic effects of electricity are to produce
surface or deep hyperemia; to induce muscular contrac-
tion, either by changes in the chemical reaction within
the muscle or through its nerve supply; to soften scar
tissue ; to hasten the healing of open wounds ; to soothe
nerve irritation and to cause the direct absorption of
drugs by ionization.
Electricity is produced by chemical action, induction
or friction, all of which types are used in the treatment
of patients.
The type of current produced by chemical action is
generated in the galvanic cell as typified by the standard
Daniell cell, which generates an electro-motive force of
one volt. The simplest form of this cell is a quart jar
two-thirds full of sulphuric acid, in which is placed a
plate of zinc, the negative pole or cathode, and a plate of
carbon, the positive pole or anode. If a wire is placed
between the upper extremities the current will flow from
the positive to the negative pole. In the solution there
is a transfer of electricity from the zinc to the carbon.
During this process bubbles of hydrogen form around the
carbon. This is called polarization and may be great
enough to block the current, in which case the carbon
36 PHYSICAL RECONSTRUCTION
should be removed and cleaned. In the dry cell a solid
substance replaces the sulphuric acid, but the action is
practically the same. Electric force may be either nega-
tive or positive in quality. Like types repel and unlike
types attract each other.
The definition of a few electrical terms is here in order.
1. Volt. That unit of electro-motive force generated
by the standard Daniell cell.
2. Ohm. The unit of resistance to the current offered
by one thousand feet of one-tenth inch copper wire.
3. Ampere. The unit of quantity of current which the
force of one volt will drive through one ohm in one sec-
ond.
McKenzie, Strong and others illustrate the meaning
of these terms by the comparison of electricity to water
power. If one water container is placed above another,
the force exerted by the water in the upper container in
seeliing the level of the lower is directly proportionate to
the difference in height, and is comparable to the reaction
between the positive and negative poles. The difference
in height represents potential energy and this force cor-
responds to the voltage of an electric current. The
amount of water allowed to flow from the upper to the
lower container corresponds to the amperage of an elec-
tric current. Upon the size of the pipe used depends
the amount and force of the stream of water. If a small
pipe is used the resistance (number of ohms) is increased,
the force of the flow (voltage) is high but the quantity
of water (amperage) is small. On the other hand, if a
HYDROTHERAPY ELECTROTHERAPY 39
large pipe is used the resistance is decreased and the force
is lessened but the quantity of flow is increased.
In electrotherapy the type of current commonly used
has relatively high voltage but very low amperage, which,
for convenience, is measured in milliamperes.
Galvanism. The ordinary galvanic battery consists of
a cabinet containing a series of cells joined to a switch-
board with binding poles, to which are attached the cords
and electrodes for applying the current to the patient.
There are also appliances for measuring, interrupting or
increasing the current.
The galvanic is a continuous current flowing steadily
from positive to negative. It is used for the following
physiological effects : stimulation, sedation, nutrition and
chemical changes. Quite different effects are produced by
the positive and negative poles. There are two simple
tests for differentiating the poles. If the ends of the
cords are placed on blue litmus paper the positive pole,
because of its attraction of acids, will turn the paper
pink. If the cords are dipped into salt solution bubbles
will collect around the negative pole, which attracts alka-
lines. Where the anode or positive pole is used, circula-
tion, muscular contraction and nervous irritability are re-
duced. At the point of application of the cathode there
is greater muscular contraction, stimulation of circula-
tion and increased nervous irritability. Having selected
the proper electrodes for the desired effect, they should
be applied smoothly and firmly to unabraded skin. It
must be remembered that the electrodes should be cov-
ered with smooth felt or gauze thoroughly saturated in
40 PHYSICAL RECONSTRUCTION
warm salt solution and should be proportionate in size
to the part treated. Burns are most likely to occur at the
cathode and this point should be most carefully watched.
The current should always be applied and decreased slow-
ly. This type of current is also applied by local bath
with one pole in the water, the other on the spine.
Ionization. Ionization is the induction of drugs into
the tissues by electrolysis. These substances in solution
may be driven in by the galvanic current. The ions of
zinc, copper and lithium, being electro-positive, should
be placed on the anode, by which they are repelled. The
ions of chlorine, potassium and iodine are electro-nega-
tive and are repelled by the cathode. "Weak solutions of
two or three per cent are usually employed.
Interrupted Galvanic Current. The constant current
has no effect on muscular contraction, but when it is sud-
denly shut off and again applied at both this break and
make of the current a contraction is produced. The
stronger contraction occurs when the current is made at
the cathode. A device called a metronome, attached to
the instrument, produces this effect.
A smoother type of galvanic current is the sinusoidal
galvanic, a current which flows evenly on the positive and
negative side alternately. It has a deeper effect on mus-
cular nutrition.
Faradic Current. The faradic is an induced alternat-
ing current, produced by charging one coil, the primary,
which then becomes an electro-magnet and when brought
into contact with a secondary coil charges it also. By
variation in the size of wire or the number of windings
HYDROTHERAPY ELECTROTHERAPY 43
on the secondary coil, the voltage of the current may
be increased or * ' stepped up. ' ' This current may be made
and broken by the withdrawal and reinsertion of one of
the coils by hand, or may be rapidly done by mechanical
interruption.
The faradic gives a harsher stimulus than the galvanic
and acts directly through the nerves, producing a defi-
nite muscular contraction similar to that of a normal
muscle. For that reason one electrode should be placed
on a main nerve trunk proximately to the muscle to be
stimulated and the other should be placed on the electro-
motor point. The difference in polarily is slight, there-
fore differentiation is unnecessary. The close similarity
of this current to the normal nerve impulse makes it par-
ticularly valuable in keeping muscles in good tone when
normal exercise is impossible.
Most machines for the therapeutic work combine the
galvanic and faradic sinusoidal currents and they should
therefore be used selectively.
Sinusoidal Current. The sinusoidal current is also in-
duced and is therefore similar to the faradic, save that
it passes in a wave from zero to the highest force on the
positive side and then back through zero to the highest
force on the negative side and then flows back from nega-
tive to positive. This surging effect produces complete
muscular contraction, but is somewhat more gradual and
therefore more pleasant than the harsh stimulus of the
faradic.
Bigh Frequency. This is an induced current oscillat-
ing from one-half to five million alternations a second,
44 PHYSICAL EECONSTRUCTION
with high voltage and low amperage. The different types
d'Arsonval, Oudin and Tesla are all used. To obtain
the current a resonator, coil (solenoid), adjustable spark-
gap and Leyden jar condensers are used.
Application to the patient is made by means of vacuum
electrodes or plates. Marked changes in metabolism are
produced with little discomfort on the part of the pa-
tient.
Diathermy. Another common use for this type of cur-
rent is the driving of heat deep into the tissues by means
of two pliable, flat metal electrodes applied on opposite
sides of the part to be treated. These electrodes should
be smoothed out and then shaped carefully to the part
and held firmly in place.
The resistance by the body increases the heat which in
turn produces marked deep hyperemia. In this way we
are able to drive heat deep into the tissue, as in the joint
cavity, and to prepare a part for massage or exercise
treatments.
Static Electricity. This current is produced by the
friction of revolving glass plates, charging brushes. Holtz
and Wimshurst machines have been varied for special
uses. The high tension obtained requires insulation.
The types of current are Morton wave for general
tonic, simple current for insomnia and ''breeze,*' sedative
effect on pain.
Sun Lamp. By means of the quartz lens light can be
split into its component parts and all but a desired wave
length excluded. The ultra-violet or actinic rays may
HYDROTHERAPY ELECTROTHERAPY 45
thus be used alone for the chemical effect. These rays
have a marked bactericidal and healing action.
The patient's body, with the exception of the part to
be treated, should be carefully covered. Operators much
exposed should wear smoked glasses. An average ex-
posure is three minutes at a distance of eighteen inches.
Very satisfactory results have been obtained in the
quickened healing of open wounds by this means in a
number of our base hospitals where these lamps are
in use.
Chapteb III
MASSAGE
Definition. Massage is the scientific manipulation of
the soft parts of the living body for purposes of health.
It is a mechanical interference with and modification of
the physiological function of the different tissues.
History. Throughout the animal kingdom we find
many instances of one animal massaging another or itself
by rubbing, licking or biting the affected part. Among
mankind it was known to the Chinese at least three
thousand years B.C., and was used somewhat by the
Egyptians and Greeks and by the Romans in their baths.
Among the Greeks, ^sculapius and his followers, the
Asclepiades, in their school of medicine on the Islands
of Kos and Knidus, were the first to systematize massage.
With the other arts and sciences it was submerged dur-
ing the dark^ages to reappear on the teaching of Pare,
Ling and Metzger in modem history. It was first used
extensively in this country by Dr. S. Weir Mitchell about
1877.
Types of Movements. There are four cardinal move-
ments used:
1. Eflfleurage or stroking.
2. Petrissage. Pinching or kneading.
46
Fig. 15. Massage. Effleurage or Stroking of Forearm.
Fig. 16. Massage, Petrissage or Kneading of Calf.
MASSAGE 49
3. Tapotement. Hacking, slapping or vibrating.
4. Frictions.
Objects :
1. To increase arterial, venous and lymphatic flow.
2. To improve skin function.
3. To soothe or stimulate the nerves.
4. To eliminate waste products.
5. To break down adhesions.
6. To reduce swollen tissue.
7. To improve nutrition.
General Considerations. Since by means of massage
we are going to interfere with the physiologic function
of tissue, a broad and thorough knowledge of physiology
is an absolutely essential basis for scientific work. Not
only the way tissues and organs act, but their structure
and location must be exactly known; therefore a com-
prehensive knowledge of the anatomy, at least of the soft
parts of the body, is of extreme importance. The too
great neglect of this valuable means of treatment has
been to a large extent due to the impression left on both
the physician and the public through the ignorant and
unscientific use of massage by a large proportion of
those claiming to be able to treat by this means. Al-
though one of the best contributions to this science was
made by the Swedes, many valuable features have since
been added to the theory and application of this form
of physical therapy. It is a mistake, then, to follow the
Swedish, or any other so-called system, to the exclusion
of others.
50 PHYSICAL RECONSTRUCTION
The proven value of this form of treatment, and the
fact that in so many serious conditions its use is indi-
cated, make it a worthy branch of the medical science.
No person can be truly successful in this work who does
not approach it from the standpoint of service and who
is unwilling to make the personal sacrifice necessary to
gain a well . rounded knowledge of the entire subject.
The high type of young women entering the work for the
army will undoubtedly elevate the plane of this field of
endeavor. Let us hope that in the mind of the general
public the athletic ''rubber" and the Turkish bath at-
tendant will be hereafter clearly distinguished from the
true masseur or masseuse.
The close personal contact with the patient makes it
imperative that the operator remain constantly mindful
of the fact that the feeling of confidence and trust on the
part of the patient is an invaluable aid toward success.
Dignity, reserve and high moral tone are prerequisites.
In an oiBfice practice it is desirable to have a couch or
a padded table about three feet high and two feet wide.
The best temperature is from 70 to 75. Only the part
should be exposed which is being manipulated. Both
hands should be trained to equal skill and during a treat-
ment are usually kept in contact with the skin. Powder
is being increasingly used to lessen skin friction and is
in many ways preferable to cocoa butter, cold cream
or vaseline. The use of ichthyol or strong liniments to
produce counter-irritation is unnecessary. The length
of the average treatment depends upon the vigor and
concentration of effort, the object desired, and the size
MASSAGE 53
of the surface to be covered, and varies from twenty to
fifty minutes.
Venous Circulation. Venous circulation runs in the
same direction as the lymphatic and is modified by the
action of the valves scattered throughout the venous sys-
tem.
Lymphatic Circulation. Its general course is from the
extremities toward the heart and is modified by ** stops,"
individual or groups of glands.
Arm. From the tips of the fingers to the axilla, espe-
cially on the, flexor side. Gland in the elbow, middle of
the arm and chain in the axilla.
Leg. Largest vessels on the dorsum of the foot, the
back of the leg, popliteal space, inner side of the thigh to
the front above. Glands between the tendo Achillis and
external malleolus, the lower part of the thigh and the
chain of inguinal glands in the groin.
Face. The upper vessels center at the root of the nose ;
the lower ones go toward the neck.
Neck. Down the front of the sterno-mastoid and in
front of the edge of the trapezius, where most of the
cervical glands are located.
Chest. Superficial glands from the inner third of the
breast toward the sternum, outer two-thirds toward the
axilla. Deep vessels toward the sternum.
Abdomen. Generally toward the inguinal glands.
Back. Superficial circulation of the upper part to-
ward the axilla ; deep circulation toward the spine ; lower
back toward the sacral notches.
Stroking is always done in the direction of the lym-
54 PHYSICAL RECONSTRUCTION
phatio and venous flow, the only exception being to re-
move secretions from an open wound.
MECHANICS AND PHYSIOLOGICAL EFFECT
Effleurage or StroMng. Stroking is done with one or
both hands or any part thereof simultaneously, alter-
nately or with one only and with varying degrees of
force, rapidity and duration, depending upon the part
massaged and the purpose in view. The object is to in-
fluence the blood and lymphatic circulations. The super-
ficial circulation is always affected, the deeper only by
added pressure. The direction is always toward the
heart with the exception noted above.
The skin is mildly stimulated, but this effect is les-
sened with the use of lubrication.
Sensory nerve endings in the skin are stimulated by
stroking and the sum total of the effect depends upon
concentration of the nerve endings in the part, the amount
of surface covered, and the number of strokes used.
Since stimulation depends upon variation, and nerve end-
ings soon become dulled to the same type and degree of
stimulus, repeated light stroking is in its sum total ef-
fect soothing.
The circulation may be greatly modified by stroking.
No measurable effect can be procured on the arterial flow.
Capillaries are dilated by strong stroking and contracted
by light stroking. Venous circulation can be markedly im-
proved. The stroking should be deep enough to compress
the vein, more rapid than the venous circulation, which
Fig. 19. Massage. Tapotement or Hacking of Muscle.
Fig. 20. (A) Posterior Half Cast to Prevent Foot Drop. (See Fig. 58
for X-Rav.>
MASSAGE 57
is not more than five inches a second, and long enongh to
extend over the next proximal valve, which would be from
six to eight inches. The lymphatic flow will be aided by
slow, deep stroking, especially over the lymph glands.
The muscle can be directly relieved in fatigue through
the removal of waste products by deep stroking.
Glands can be stmiulated by the indirect effect of cir-
culatory changes in the skin.
In such bones as the tibia the periosteal circulation
and nutrition can be aided.
Several writers have called attention to the different
effects produced on muscle tissue by the different types
of massage. They consider light stroking to be both
soothing and relaxing and therefore indicated in spastic
contracture. Others do not massage spastic muscle at
all.
Petrissage. Pinching, Kneading. This type of mas-
sage is used mainly for its effect on muscle tissue. The
amount of tissue grasped would then depend upon the
part being massaged. Fine pinching is done between the
thumb and first finger. Coarser pinching between the
thumb and the side of the second phalanx of the first
finger, or the thumb opposed by the tips of all the fingers,
is good on a flat surface, such as the back ; to this twist-
ing may be added for more vigorous effect. The hands
may be used effectively close together and alternately,
one pinching while the other is re-grasping.
On the extremities the hands may be used on opposing
sides, completely grasping the various muscle groups.
The direction of the pinching should be at right angles
58 PHYSICAL RECONSTRUCTION
to the muscle fibers. On the abdominal wall, where we
are unable to obtain selective action on the different
layers of muscle, it is well to knead in concentric circles.
Pinching the muscle fibers brings about a partial con-
traction of those having their nerve supply intact. Some
orthopedists believe a beneficial or a stimulating effect
may follow even where we find that the nerve supply
is entirely lacking. It is easier to obtain a partial con-
traction of a large number of fibers, or a complete con-
traction of a few by this means than by the use of elec-
tricity. Since only the stimulated part of the muscle re-
acts, we may by this means keep up the tone and health
of muscles in the immediate neighborhood of inflamed
joints, yet at no time cause an undesired movement of
the joint. For this partial effect the different nerve sup-
plies and the several heads of the various muscles must be
kept in mind. A beginner should early learn to differen-
tiate in infantile paralysis the thick, fat and connective
tissue layer which so often overlies the muscle and upon
which, without due care, the petrissage may be directed
from the muscle itself. ^
Tapotement. Hacking, slapping, vibrating. This pro-
cedure is aimed at the skin and the muscles.
Skin slapping should be done with light, fast, alternate
strokes. The wrist should be relaxed, each hand instant-
ly rebounding from the skin. Superficial blood vessels
and later the deeper vessels are quickly dilated in this
manner.
Over groups of muscle the strokes are made alternately
with the ulnar sides of the hands. Here, too, the wrists
Fig. 21. High Explosive Wound of Left Hand.
Loss of third and fourth fingers and part of hand. Function good following
exercise and massage. (X-ray Fig. 22.)
Fig. 22. Loss of 3rd and 4th Metacarpals.
MASSAGE 61
should remain relaxed, the hand nearly open, the fingers
slightly separated. In this manner the fourth finger
strikes the part first, the others following in turn. For
harder striking, to relax a knotted muscle, for instance,
the hand may be held rigidly extended and the strokes
given more heavily, only the ulnar side of the hand and
little finger striking the part.
Another method is by the use of the partially clenched
hand, palm down, striking flat with the second phalanges
of the fingers.
Vibrating can be done by keeping the finger tip or
other parts of the hand in contact with the patient, the
wrist relaxed, and performing a shaking motion of the
whole arm.
The stimulation resulting from this method depends
upon the number and force of the strokes and the amount
of surface covered.
Frictions. Frictions are seldom used except on ad-
ventitious tissue in a number of pathological conditions.
The breaking up of scars and adhesions forms an im-
portant part of its usefulness. We generally approach
such tissue by concentric circles starting well out at the
periphery. Frictions of the spine are sometimes used
to stimulate the nerve roots. This manipulation is also
valuable in the reduction of callus.
THERAPEUTIC USES AND CONTRAINDICATIONS
Skin. Where the skin is dry, harsh and cold, slapping
will dilate peripheral capillaries, warm the skin and in-
duce perspiration. Oold, clammy, moist skin can be
62 PHYSICAL RECONSTRUCTION
aided by frequent light stroking centrally above the part
to aid the venous circulation.
Glands. Inactivity of the sebaceous glands, followed
by the formation of blackheads and pimples, often oc-
curs where the skin is normally rather immobile. Mas-
sage will improve the circulation, mechanically squeeze
out the inspissated secretion and restore normal gland
activity.
Dandruff is the result of hypersecretion of these
glands in the scalp. The oil not being fluid enough, in-
stead of supplying the hair it collects in layers around the
gland openings and flakes off. The hair not being prop-
erly oiled, tends to dry and break off or split. Massage
of the scalp will stimulate gland activity and the return
of the sebaceum to its normal fluidity.
After chronic inflammation of the skin, for instance,
as caused by boils or carbuncles, scar tissue may be re-
duced.
Scars. It must be remembered that scars are com-
posed of connective tissues only and contain no sweat or
sebaceous glands and no touch, pain, or heat corpuscles
and are the result of wounds not healing by first inten-
tion. Frictions over and around scars will reduce the
amount of tissue in duration and the size of the scar
itself. Massage will prevent tissue contraction.
Atrophy. This condition is commonly seen after the
wearing of casts or on the soles of the feet after pro-
longed rest in bed. Massage is extremely useful here
in restoring skin function and hardening the soles of the
feet preparatory to walking.
MASSAGE 63
Contraindications. 1. Hypersensitivity of the touch
corpuscles, which may, however, reflect the same state
of the mind, contraindicates massage. Parts covered
by hair must be well lubricated or shaved. This shav-
ing does not stimulate the growth of hair as much as does
the repeated irritation caused by the pulling of the mas-
sage itself.
2. Pimples or skin infection are not massaged. In case
it is necessary to stroke a skin covered with blackheads
and pimples, clean thoroughly before and again after
the treatment with alcohol or soap and water.
CAEDIO-VASCXJLAB SYSTEM
The Heart. The heart can at times be stimulated by
tapotement directly over its location, or this procedure
over the stomach may greatly relieve cardiac embarrass-
ment caused by gas formation there.
Pericarditis. Here the heart laboring under mechani-
cal difficulties which retard its action can be relieved by
stroking of the extremities, thus removing some of its
normal work.
Myocarditis. In the same way a weakened or inflamed
heart muscle can be relieved of some of its load. This
very obvious fact in therapeutic indications for massage
has been almost entirely overlooked by the general pro-
fession. Graded muscular exercise should, if possible,
be given in conjunction with massage.
Endocarditis. This condition can be aided in the same
way and, since cardiac dilatation is sometimes due to back
64 PHYSICAL RECONSTRUCTION
pressure from the venous system, this mechanical aid
should never be withheld.
Contraindications. Tapotement and the more vigorous
types of massage may often be useless, but gentle strok-
ing in the direction of the venous return will always aid
a heart working under a handicap. Acute endocarditis
and purulent myo- or pericarditis and angina pectoris
contraindicate massage.
Veins. Dilatation of the veins may be treated by ele-
vation and stroking, which may, especially in the veins
of the lower leg, prevent them from becoming varicose.
Varicose veins cause a great deal of extra work to be
thrown on the heart through venous stagnation. Massage
by gentle stroking above and below. When the dilata-
tion is not marked or any sign of ulceration present,
slow, gentle stroking may be done directly over them.
Phlebitis. Here the walls thicken, a sign of inflamma-
tion in the vein, which may greatly enlarge, become ad-
herent to the surrounding tissue or break down and ul-
cerate. Later joint contractures may form in the knee
or elbow. Elevation and rest should be given in the
active stage. Later on gentle frictions and stroking at
the sides over the non-inflamed veins and above and below
the inflamed part, to aid in removing the swelling, is of
value. Contraindications. In varicose veins any pro-
cedure except stroking is to be avoided and even this is
not done when the walls are thin or ulcers have formed.
In phlebitis, during the active stage, or at any time di-
rectly over the vein, avoid massage for fear of freeing
a thrombus.
MASSAGE 65
Lymphatics. Dilated lymph capillaries and spaces may
be massaged with stroking and deep pressure centrally,
with light friction added over the lymph nodes. Eleva-
tion is helpful. Contraindications. Active inflammation
contraindicates all direct massage.
Arteries. No disease of the larger arteries is amenable
to massage treatment. The compensatory circulation
may be improved in obliterating endarteritis. Arterio-
sclerosis usually begins in the capillaries and arterioles
in the distal extremities, the left leg being often the first
point of onset. The X-ray may show this condition. Tor-
tuous temporal arteries, arcus senilis, palpation of the
radial artery and high blood pressure are other means
of determining its presence. A general massage con-
tinued for years and well done on the extremities and
the veins of the surface will often arrest the progress of
this disease and may give partial recovery. The mental
attitude of these patients is greatly helped and this is
a most desirable and important element in the treatment.
Contraindications. Tapotement, when the condition is
at all advanced, and in aneurism, should not be used.
MUSCULAB SYSTEM
Myositis. Muscle soreness follows the insufficient re-
moval of fatigue products. Stroke centrally above the
muscle to open up the lymph channels and then stroke
over the muscle.
Knotted muscle, which occurs in athletes, especially
track, after severe exertion, is the next stage of the same
process, but includes as a rule the tearing of a few fibers
66 PHYSICAL RECONSTRUCTION
with some serous exudate into the muscle tissue. Pro-
ceed as in muscle soreness just described but the stroking
of the muscle itself should be deeper and of greater dura-
tion with some friction added.
Muscle Bruise. Here, in addition, occurs hemorrhage
into the muscle with discoloration. If treated at once,
it is dealt with as in knotted muscle. Later the fibrin
glues the muscle fibers together and deep frictions must
be used to break it up. Work in concentric circles. If
neglected for some time the blood clot may become or-
ganized and a great deal of exertion must be put into the
massage and a longer time given to the treatment. Vig-
orous tapotement should be added. Occasionally it may
be necessary to make the muscle '* black and blue" again
by this means before the organized mass can be broken
up and the free play of the bundles restored.
Torn Muscle. This is usually associated with severe
bruising and is followed by true scar formation within
the muscle. This scar must if possible be reduced and
broken up in the same manner as for a bruise, but the
part should be immobilized between the treatments. The
bandaging should start above and below and work to-
ward the tear, thus keeping the fibers approximated. It
is evident that tight bandaging started directly over the
lesion would force the fibers apart and increase the
amount of scar formation.
''Charley Horse'* is a subperiosteal hematoma which
follows deep bruising that involves the periosteum, tear-
ing some of its blood vessels. Frictions and stroking will
prevent organization and hasten reabsorption. This is
MASSAGE 67
a common football injury of the front of the thigh and
its presence is indicated when, with knee raised forward,
the patient is unable to extend the leg. Contraindica-
tions: Purulent myositis, trichinosis, and muscle wounds
should not be massaged.
Atrophic Muscle. The commonest condition we deal
with here is infantile paralysis. The lesion is primarily
in the motor and trophic nerves ; occasionally the sensory
are involved. While massage is aimed at aiding nutrition
and stimulating any muscle cells and nerve endings that
may be alive, we must remember in children how de-
pendent we are for growth upon contact stimuli. These
are usually lacking, but can to some extent be supplied by
massage. Slapping and light tapotement with open fin-
gers are useful, and fine pinching, which must penetrate
the layer of fat and connective tissue and be directed on
the muscle fibers, is of great value. The intrinsic power
of all muscle tissue to contract is thus stimulated even in
the absence of motor impulses. Contraindications: In
the active stage of infantile paralysis no massage should
be used, and in advanced atrophy of old age or convales-
cence only stroking is indicated.
Spastic Muscle. Stimulating massage of the physio-
logical opponent is good and on the muscle itself gentle
stroking, which is now believed to be relaxing, aids the
condition. Some authors, however, call all massage oon-
traindicated in spastic muscle.
Sarcolemma or Muscle Sheath Inflammation. This
structure is often inflamed in places where a large number
of muscles lie close together and considerable friction de-
68 PHYSICAL RECONSTRUCTION
velops during their overuse, as in the neck, forearm and
calf. The ' ' spike soreness ' ' of track men is of this type
in the opinion of some writers ; others class it as a neu-
ritis. Rest, baking and elevation are invaluable adjuncts
to massage stroking. Try to get between the muscles
with the tips of the fingers. In chronic cases where there
may be organized deposits, use deep friction followed by
stroking.
Tendon Sheath Inflammation. Tendons themselves sel-
dom are inflamed or injured. The sheath acts as a deli-
cate insulation within which the tendon moves. This
movement requires constant lubrication by a fluid se-
creted by cells in the inner layer of the sheath. Overuse
will exhaust this fluid and set up an inflammation (teno-
synovitis). Overproduction of fluid then takes place,
distending the sheath with pressure on adjoining struc-
tures. Fibrin may coagulate within the sheath and form
a painful, semi-solid swelling. In the vn:ist and ankle the
annular ligaments may partially shut off a portion of the
tendon sheath and, aided by gravity, hasten coagulation.
Occasionally the fluid may enter a joint cavity and float
the bones apart with a tendency to sprain and dislocate.
Any mechanical interference in the absorption of the ex-
cess fluid, unless it be a snugly fitting bandage from the
extreme distal part completely over the entire swelling,
may be injurious ; hence wrist and ankle supporters often
do more harm than good. The tight lacing of high shoes
is a common cause or an aggravation of this condition.
Treat by heat, rest, removal of constrictions and ef-
fleurage, with frictions if any coagulation is present.
MASSAGE 69
Contraindications. Wounds and pumlent inflammations
should not be massaged.
BONES
Periostevm. Chronic periostitis may be greatly aided
by deep stroking, especially in bones, like the tibia, which
are practically subcutaneous.
Scar formation following tears may be lessened by
friction and stroking.
Hemorrhage beneath the periosteum has been de-
scribed under diseases of the muscle.
Fractures. The large callus that usually follows frac-
ture repair may be reduced by frictions. These calluses
may include some of the soft parts which must first be
liberated. Deep frictions working circularly from the
periphery to the center are best.
The action of the muscles may be greatly hindered by
having to work over such an enlargement. Occasionally
there may be great pain and discomfort from this condi-
tion. Even a small callus may cause trouble if situated
near the joint. Fractures involving joints, which have
been so common in the European war, have proven the
indispensability of massage treatment to reduce callus
and to break up foreign bodies and adhesions. Callus
formation interfering with joint movement may be too
soft to be disclosed by the X-ray and yet demands atten-
tion.
Faulty Metabolism. Such conditions as rickets may
be greatly aided by massage aimed at the circulation.
General body massage is often indicated and improved
70 PHYSICAL RECONSTRUCTION
nutrition of the bones leads to increased formation of
red blood corpuscles. Contraindications. Immediately
after fracture and in acute inflammations, osteitis, os-
teomyelitis and periostitis, massage is not used.
JOINTS
Dislocations. Gentle friction and stroking will aid the
healing of the torn ligaments. In certain joints, for ex-
ample, the shoulder, there is a tendency for the disloca-
tion to recur and here the treatment should be delayed.
Sprains. These should be massaged at once in spite
of pain. Deep strokes and frictions aid in the removal of
extravasated blood and help to prevent its clotting. If
the case is not seen until the clot has organized it must
be broken up by deep frictions followed by stroking. If
this is not done the ligaments heal over the clot, which,
when it is finally absorbed, leaves the ligaments elongated
and relaxed with a tendency to frequent recurrence. As
I have before emphasized, there is no treatment available
superior to this, coupled with a support to prevent re-
sprain.
Synovial membrane is always involved in joint injuries.
There is an increased secretion of synovia by means of
which nature attempts to float apart the two inflamed
surfaces. This results in lateral insecurity of the joint
and this is where support is indicated. In the case of the
knee a posterior splint, which is commonly used, is not
the preferred treatment but a lateral hinged brace, which
prevents twisting and lateral strain, but allows normal
hinge movement, is indicated. Because of the relatively
MASSAGE 71
poor blood supply, such injuries heal rather slowly, but
a week should suffice in the ordinary case. When repair
is delayed much beyond this time suspicion of the pres-
ence of toxins should lead to careful examination of the
teeth, gastro-intestinal tract, etc. Baking and counter-
irritation are of value. Massage should consist of ef-
fleurage above and over the sprain. In the chronic or
subacute stage the excess of fluid is absorbed, leaving
a gelatinous residue containing fibrin, which tends to
coagulate. Hard frictions, getting as deeply inta the
joint as possible, are then indicated. If coagulation has
taken place, small particles may be broken off and become
loose in the joint. In the knee the so-called **rice kernels"
are of this type. Here the joint should be fully flexed to
open it up and moved several times during the treat-
ment to shift the particles under the fingers. The next
stage in untreated cases, or in repeated sprain, is a thick-
ening of the synovial membrane which may not be ap-
parent for two or three weeks. Here, too, the joint be-
comes insecure with tendency to subluxation and re-
injury. The synovial membrane becomes thick and
spongy and rolls between the bones like dough before a
rolling-pin and a fold or crease in front or rear may
limit joint movement. Normal movement, well protect-
ed, still tends toward cure, but as a rule heat and mas-
sage must be continued for months before permanent re-
covery takes place. Contraindications. Infective in-
flammations, toxic inflammations when most acute, and
dislocation while unreduced should not be massaged.
72 PHYSICAL RECONSTRUCTION
NERVOUS SYSTEM
Brain Diseases. The quieting effect of stroking, espe-
cially of the back, may be of service in mild states of
mental agitation. After a prolonged agitation, sys-
tem exhaustion may be lessened by complete massage
treatments. The persistent chronic constipation asso-
ciated with many of these disorders may be relieved by
abdominal massage of the type to be described.
"Softening of the brain" resulting from faulty circu-
lation in localized areas cannot directly be affected.
When it involves motor areas, however, the affected mus-
cle should be treated by reeducational gymnastics and
"muscle massage."
Apoplexy. Downward stroking of the veins of the
neck relieves congestion. Treat the paralyzed muscle by
"muscle massage." This has not only a distinct local
beneficial effect but a pronounced sedative influence upon
the patient's mental condition. Contraindications. In
acute inflammations of the brain, meningitis and hyper-
susceptibility massage should not be used.
SPINAL DISEASES
Injuries. The spine cannot be directly stimulated be-
cause of its location.
Infantile Paralysis. Stroking of the back may be
beneficial in the subacute stage. Local massage of the
affected muscle should not be begun until tenderness has
entirely disappeared, but thereafter it must be continued
MASSAGE 73
until recovery or for a number of years. Contraindica-
tions. The acute stage contraindicates massage.
Functional Diseases. Improvement in diagnosis and
recent researches are bringing us more and more to the
point of view that pure functional neuroses are extremely
rare, and that there is usually an organic or functional
lesion somewhere. This should be diligently sought and
if found removed.
Neurasthenia. The nervous and bodily weakness ac-
companying this condition is more efficiently treated by
regular and complete massage than by almost any other
method at our command. Both mentally and physically
great benefit is usually obtained. The muscles are kept
in good health and tone without the expenditure on the
part of the patient of the energy which exercise would
require. Later on massage should be supplemented by
graded exercise.
Hysteria. General massage is indicated here when
possible for its general tonic effect. Contraindications.
Violent hysteria should not be treated by massage.
Peripheral Nerves. Thickening of the nerve sheath
following injury can sometimes be relieved by light strok-
ing. The nerves are often caught in scars following frac-
tures or extensive tissue destruction. They must be
loosened up and relieved from the pressure by passive
movements, friction and stroking.
Neuralgia. This is a symptom, not a disease. Mas-
sage may help to remove the cause. It is contraindicated
on the affected part.
Neuritis. This is commonly a result of some constitu-
74 PHYSICAL RECONSTRUCTION
tional poison and the massage is directed toward helping-
the body eliminate the causative agent. The muscular
atrophy which usually accompanies severe neuritis can
be retarded. Contraindications. Massage over the af-
fected nerve is contraindicated.
ABDOMINAL VISCERA
Stomach. Vigorous tapotement directly over the
stomach will often assist in the elimination of gas which
may, beside causing local distress, be embarrassing the
action of the heart.
Intestines. Chronic Constipation. This is one of the
most common distressing and truly important conditions
with which we are concerned. Among the common causes
are enteroptosis with stretched mesentery, partially oc-
cluding the blood vessels and resulting in atonic muscula-
ture. The mechanical stimulation to proper peristalsis
is dependent upon the presence of a fairly large bolus
within the intestine and then a period of rest. This means
regular meals and not the constant nagging of small
amounts of contents without rest periods. It also re-
quires that we eat a reasonable amount of indigestible
residue, largely cellulose, to maintain the required bulk.
Lack of normal secretion within the gastro-intestinal
tract, adhesions and lack of the formation of regular
habits of attempt at evacuation may also be important
causes. Long dependence on drugging is unwise. We
must first not only eliminate, if possible, the cause but
bring to our assistance every factor that will aid in the
return of the normal function. Bodily exercise and espe-
MASSAGE 75
cially abdominal exercise of the type outlined for lordosis
is very eflScacious. By massage we may increase the tone
of the abdominal muscles, thereby lessening ptosis, and
in most cases we may directly stimulate intestinal mus-
cle coats. Deep pressure with the heel of the hand or
the fist should begin over the cecum and follow the course
of the large intestine. Circular stroking should follow
the same course. Deep frictions should be thorough at
the hepatic and splenic flexure, where deep stroking from
back to front between the lower ribs and the pelvis should
be vigorously applied. On the left side the ulnar sur-
face of the hand in many cases may follow the sigmoid
flexure for quite a distance downward and forward.
Liver. Tapotement over the ribs covering the liver,
circular frictions over its free edge and gentle depression
of the movable ribs will stimulate hepatic activity.
Pancreas, kidneys and bladder are not treated by mas-
sage.
Hernia may be aided indirectly by bettering the nutri-
tion of the abdominal wall muscles, especially where a
truss is worn. Contraindications. Any abdominal ten-
derness, pregnancy, and all acute infectious diseases con-
traindicate massage.
Scalp. The scalp is often rather tight and its circula-
tion somewhat impaired. It can be loosened by finger
tip friction with considerable benefit to the circulation
and the growth of hair.
Limb Stumps. In all its range of usefulness massage
gives no more gratifying results than in the preparation
of stumps for artificial limbs. In a great number of cases
76 PHYSICAL EECONSTRUCTION
at the Walter Eeed Hospital in Washington careful mas-
sage has worked wonders.
During the war many of the stumps were, under stress
of circumstances, operated on in such a way as to make
it extremely difficult to prepare them for weight bear-
ing. The chief pressure from an artificial limb is lateral,
but the soft tissue must be drawn down to form a cushion
over the end of the bone. Massage should be begun at
the earliest possible moment regardless of whether or
not the wound is healed. If effleurage is used great care
should be taken to prevent drawing up of the muscles.
The stroking should be mostly downward. Vibration
and friction are used concentrically from above down-
ward, loosening the scar and working to the very edge
of the new formed tissue over and around the end of the
bone. Where this technique is followed very few of the
blue, cold stumps, such as were common earlier in the
war, result and the whirl bath for theirrelief is unneces-
sary.
Simmmry. I would again emphasize the fact that it
is necessary to know thoroughly anatomy and physiology
and the reaction of the various tissues to strain, injury,
under-nourishment, etc. With this knowledge, and a gen-
eral idea of the technique of the main movements, the
masseur is at liberty to develop his own special technique
and method of procedure. One so equipped is in a far
better position to perform successful and helpful work
than one working merely from the mechanical standpoint,
be he ever so efficient in any given system or school of
massage.
It paEECS tiire pieafaritly
Fig. 23. Basket-m.\ki.ng.
Can be begun while the patient is still hediiddtn.
and has therapeutic value in hand and wrist injuries.
Fig. 24. Telegraphy.
Instruction begins at the bedside and is carried on through the shop to fold
work.
i'lU. 2."). ('lav AIoDKl.lXG.
One of the most valuable therapeutic measures for joint mobihty in the
fingers and hand. It can be used very early in cases where more complicated
work ia impossible.
Fia. 26. Chair Caning.
A trade of great vocational value with many varied movements of the hand
and arm which aid in restoring function.
Fig. 27. Wood Toy Making.
Ps3rchologically most patients become like children for a time. They are then
easily interested m toy making. Later this interest and incentive to work is
transferred to other things.
Chapteb IV"
VOCATIONAL THERAPY
This branch of physical reconstruction is growing most
rapidly in its breadth of application to war injuries. The
problems met and overcome so successfully are those
which must in the future be met by the surgeon in civil
practice. The work done and the lessons learned will be
of the greatest value to the compensation insurance com-
panies whose interest in the men crippled in industrial
life closely parallels the economic interest of the govern-
ment in the soldiers. Insurance companies have of late
recognized that treatment of the insured by physiotherapy
in many cases is a paying investment, the men being
returned to partial or complete eflBciency at a much earlier
date than would otherwise have been possible. It is cer-
tain that vocational therapy will in the future play an
increasing role in the treatment of convalescent em-
ployees. The larger manufacturing concerns which take
care of their own compensation cases would in like man-
ner gain much from a careful consideration of these mod-
em methods of treatment, which have proven their effi-
ciency in far too large a group of cases to ever be con-
sidered fads. The facts are that we have as yet ex-
hausted but a small part of the possibilities which these
methods of treatment hold forth.
79
80 PHYSICAL RECONSTRUCTION
Specifically, the objects of vocational therapy are thera-
peutic, economic, occupational and to improve morale.
In the early treatment of men in the army the therapeu-
tic indications control to a large extent the type and
amount, or dosage, of work outlined for a patient. For
example, a man with scar tissue contracture or fibrous
adhesions in the elbow joint, allowing only limited motion
in semi-flexion, may be put at planing in the carpenter
shop. This treatment is given the man as far as possible
on the prescription of the surgeon, as shown on page 59.
Such a prescription is given as soon as the man has suffi-
cient strength, motion and muscular control to make some
movement possible, this beginning usually having been
obtained by the preliminary application of physiotherapy.
For some time the man may be treated by the suitable
physiotherapy methods together with this simple occu-
pational work. With the lessening of his disability the
problems of his future value to himself and society are
taken up. The patient is either given training in work
which he has done before or takes up new work which
will bring him reasonable financial return and in which
his interest has been already aroused. If his disability is
such that he is unable to return to any occupation com-
parable to the one in which he was engaged in civil life
after the best surgical and vocational expert advice and
treatment, he is then trained in some line in which his
injury handicaps him little. His degree of disability in
its relation to his future earning power is calculated and
the difference made up to him.
Certain types of vocational training have as their main
VOCATIONAL THERAPY 81
object the arousing of the patient from the mental and
physical lethargy into which he is so apt to fall. For this
purpose basketry or any simple creative work which oc-
cupies his time and interest has proven of great value.
Study with a teacher of the simple branches of learning
is also used to good advantage.
Interwoven throughout a man's entire treatment is the
inspirational idea. The personality of the teacher is, of
course, of prime importance. These men are so often left
with the belief that their disability has permanently un-
fitted them for their place in society that the time allowed
them for introspection may be more destructive to their
future efficiency than the wound itself. That these men
do not lack courage their glorious record has proven.
The problem lies in properly arousing . their grit and
stamina, which, during their stay in the hospital, has
become gradually inert. The man must be made to real-
ize that the noblest of all courage is the conquering of
physical handicaps by patient endeavor and that both the
instructor and the government realize the quality of man-
hood which such a successful fight requires through weeks
and months of persistent effort. Too much cannot be
said in praise of the splendid corps of aides who are
carrying their own discouragements in addition to lifting,
to the best of their ability, those of the men whom they
serve. Their work will live in the years to come through
the increased efficiency with which these men will carry
on.
For the proper attainment of the man's rehabilitation
a close and active cooperation must be obtained between
82 PHYSICAL RECONSTRUCTION
the surgical, physiotherapy and occupational depart-
ments. It is essential that each understand and appre-
ciate the scope of the others. Between the man's voca-
tional training and his final status in civil life stands a
most important and efficient organization, the Federal
Board for Vocational Training. This organization is
prepared to give expert advice on the selection of future
work. It also aids the man financially to obtain better
training even to the extent of paying his tuition in voca-
tional training schools or colleges until he has reached the
best preparation of which he is capable. This done, the
government's debt of honor to the wounded man is met
and he is returned to civil life and self-support. Let us
hope that never again the old pension system with its
paternalism and attendant evils will have a place in the
government's care of its veteran soldiers.
In such a book as this no detailed description of the
methods used in the some two hundred and fifty occupa-
tions taught to convalescent soldiers can be undertaken.
I will, however, briefly state a few of the most useful
methods employed. At the bedsides are taught basketry,
clay modeling, wood carving, leather and bead work,
making of simple toys and the beginning of the studies of
English, mathematics, stenography, telegraphy, etc. In
the shops are taught carpentry, photography, automobile
repairing, vulcanizing, modem machine shop practice,
pattern making and a wide variety* of other trades. In
the class rooms stenography and typewriting, wireless
and the common branches of language and mathematics
are a few of the subjects taken up. This is further de-
*
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Fig. 28. Teaching the Beginnings op Mechanical Principles.
Toys are here being made from tin cans.
VOCATIONAL THERAPY 85
veloped, where possible, by field work in electrical con-
struction, surveying and other outdoor occupations.
Of special interest to the general hospitals wishing to
add vocational training to their equipment is the curative
workshop. This is an attempt to combine the simple
forms of vocational work requiring only inexpensive
equipment and limited space. The therapeutic indication
is the leading motive for treatment. In such a workshop
we would find clay modeling, which has proven invalu-
able in the treatment of stiff fingers and wrist. The
scroll saw and various lathe machines with adjustable
pedals offer unlimited possibilities for increasing mobility
of hip, knee and ankle. A simple kit of tools suffices for
mechanical drawing, wood working, shoe making and
similar occupations.
The talent of an artist is not destroyed nor his means
of expression lost when a physical disability interferes
with the particular method of drawing, painting, or play-
ing which he had formerly used. There are several cases
on record for artists following injury of the right hand
have quickly learned to work equally well with the left.
In the same way musical talent can be utilized. Pro-
fessional musicians are used in an advisory capacity to
aid men to choose that instrument or mode of musical ex-
pression which is not interfered with by his disability.
There is another value to this type of treatment which
must not be lost sight of and that is the inspirational ef-
fect of the music itself. Many a man will spend happy
and beneficial hours in the music studio instead of giving
86 PHYSICAL EECONSTRUCTION
way to the mental depression and discontent of the in-
valid.
In the early spring of 1919 there were already over fifty
thousand patients in this country under treatment by a
corps of something over three thousand aides who are
teaching, as before mentioned, between two and three
hundred subjects. Vocational therapy will see increasing
growth and development, and must necessarily be one of
the last to be discontinued when this big chapter of our
country's history is closed. I wish again to emphasize
that the medical profession owes the same intelligent care
to our great industrial army which the government has
so efficiently given to its veterans of the Great War.
Fig. 30. Musical Knowledge Reapplied to an Instrument the Man's
Disability Will Allow Him to Play.
Pleasure and higher emotional tone are derived from the production of good
music.
Fig. 31. Automobile Repair Shop.
This is one of the most practical, valuable and popular forms of vocatio
therapy.
Fig. 32. Wood Working.
Gives many possibilities for self expression, arouses the creative interest
and exercises almost innumerable muscle groups.
VOCATIONAL THERAPY 89
(Orthopedists have found the following simplified form useful
in briefly outlining the reconstruction treatment which they con-
sidered best suited to the needs of the patient.)
EDUCATIONAL SERVICE
U. S. Army Base Hospital
Camp Meade, Md.
MEDICAL OFFICER'S PRESCRIPTION
Name
Ward 191 .
Diagnosis
Probable length of stay in hospital weeks.
Probable condition after completion of hospital treatment
Functional result to be attained.
In orthopedic cases check below:
.Abduction ..Thumb ..R....L
.Adduction ..Finger
. Flexion ' . . Wrist
.Extension ..Elbow
. Pronation . . Shoulder
. Supination . . Back
. Circumduction . . Toes
. . Mid-Tarsus
. .Ankle
..Knee
..Hip
Remarks
90
PHYSICAL EECONSTRUCTION
PRESCRIPTION BLANK. FOR VOCATIONAL THERAPY
Please check below the general class to which this man's dis-
ability belongs, using double check for major disability and single
check for minor.
MEDICAL CONDITIONS
Cardio-vascular
Pulmonary Tuberculosis
Fimctional Neurosis
Insanity
Nephritis
(rastro-intestinal
Skin Disease
Gassed
Convalescent
Other general medical
SUBOICAL CONDITIONS
Orthopedic
Amputation
Eye, Ear, Nose
Throat Disease or Wound
Nervous System
Blindness
Deafness
Speech Defect
Severe Injury to Face or Jaw
Venereal Disease or Sequelae
Surgical Condition of
G.-U. System
Venereal
Non-Venereal
Other surgical conditions
Convalescent
This man is ready for assignments checked below (please i
elude all of which he is capable) :
Work in wards: Mental Physical
Classroom work not to exceed hours and minutes
daily.
Shop or farm work ....
Hours per day ....
Light Heavy
Outdoor Indoor
To be avoided
Medical Officer's Signature
(This prescription will be filed in the Surgeon General's Office
as a part of the Physical Reconstruction Register.)
PART II
ORTHOPEDICS
Chapter V
CONGENITAL DEFECTS
Club Foot. As this common condition is much more
often congenital than acquired, the congenital type only-
will be considered. There are four types. The deformed
foot (talipes) may be, 1. Extended and everted, equino
valgus. 2. Extended and inverted, equino varus. 3.
Flexed and everted, calcaneo valgus. 4. Flexed and in-
verted, calcaxeo varus. Simple talipes equinus is dis-
cussed under muscle-bound foot.
These deformities vary greatly in their resistance to
corrective measures. Eesistance in any given case in-
creases with age, therefore treatment should be begun
as early as possible. In very slight cases manual correc-
tion alone may suffice. In the more marked types a se-
ries of casts must be used. In the commonest type,
equino varus, emphasis must first be placed upon straight-
ening the foot, flexion being easily obtained later on if
necessary by tenotomy. The series of casts should be
as nearly continuous as possible and each should remain
on about two weeks.
Hip Dislocation. This condition is more common than
is generally realized and the difficulty of reading X-ray
91
92 ORTHOPEDICS
plates makes it necessary to use the utmost care in diag-
nosis. A neglected hip means an undeveloped or shallow
acetabulum into which it may be impossible to place the
head of the femur later on. It interferes with the devel-
opment of the bones and tends to an asymmetrical pelvis.
The table devised by Hibbs of New York has been used
very successfully in diflScult cases. Care must be taken
not to overreduce and create a dislocation in the oppo-
site direction, as has often been done.
BICKETS
Cause. We find rickets most prevalent among negro
and Italian children of the first generation. It is caused
by a lack of suflBcient lime salts in the bone, primarily
because they are not supplied in proper amount in the
diet. The prolonged nursing of children to the fifteenth
or even eighteenth month is perhaps the commonest cause.
The dependence upon macaroni as the staple Italian diet
accounts for a good deal of it.
Diagnosis. The large, square head with overhanging
forehead and delayed closing of the f ontanelles ; enlarged
epiphyses of the long bones; the beading of the sternal
end of the ribs, so called rachitic rosary ; the prominent,
hard abdomen, and a tendency to draw up the legs, are
the main early symptoms of the disease. Later on, bow-
ing of the legs or knock knees develop.
Treatment. Improved hygiene, especially in regard
to diet, fruit juices, particularly orange, green vege-
tables, fresh milk, eggs, etc., is essential. Massage is a
yaluable adjunct of the treatment. Braces are usually
CONGENITAL DEFECTS 93
needed and must be faithfully worn. Even in rather se-
vere types of bow leg one brace will often suffice. If not
it can be changed over or an additional brace made for
the other leg. Anterior and very severe lateral bowing
often call for surgical interference. A careful study of
the epiphyses by the X-ray is very essential in order to
determine the optimum time to operate when true bone
has just begun to be rapidly deposited. Knock knee as
well may call for surgical intervention guided by the
same principles. It must be emphasized that permanent
injury may be done to the knee joint rather early in
neglected cases and that, with each additional degree of
deviation from the normal line of weight transmission,
a very great amount of additional strain is thrown upon
the structures of the knee.
Coxa Vara. This is a decrease in the angle between
the surgical neck and the shaft of the femur with con-
sequent shortening of the affected leg and change in the
normal line of weight transmission. Its effect is similar
to but not usually as pronounced as that described as
resulting from congenital hip dislocations. It calls for
a long stilt brace on the affected leg to transmit the
weight of the body from the pelvis to the ground, the
weight of the leg giving some extension. The shoe on the
unaffected side should be built up.
Spastic Paralysis. Central motor neurone lesions most
often found in prolonged labor or instrumental delivery
result in spastic paralysis. The only immediate relief of
this condition is decompression, as performed with con-
giderable success by Dr. Sharpe of New York, but even
94 ORTHOPEDICS
under most favorable conditions a happy result is not
certain. The associated retardation of mental develop-
ment greatly complicates the problem of neuro-muscular
education. Treatment by effleurage and passive stretch-
ing should precede exercises for coordination and bal-
ance. To bring lasting results these must be extended
over a span of years. Every case can be improved and
should be a challenge to us to obtain the greatest improve-
ment possible, even when complete recovery is hopeless.
Fig. 33. Carriage which Reduces Friction axd on a Smooth Surface
Allows Wide Range of Movement with Slight Effort.
Fig. 34.
Wire Cockup Splint for Wrist Drop, Light in Weight, and Re-
quires No Bandaging.
Chapter VI
INFANTILE PARALYSIS
In infantile paralysis the lesion is a destructive one of
the anterior horn cells of the cord and the lower motor
neurones and almost always the resulting paralysis is
a flaccid one. The trophic nerves are likewise affected
and the part tends to decrease in bulk as well as in power.
During the active stage, and while ^ny tenderness per-
sists, the patient should be kept immobile. This is best
done by means of a cast or splint, but immediately there-
after for an extended period of time, daily treatment
consisting of massage, exercise, support and sometimes
heat, should be instituted. Massage should be mainly
fine, deep petrissage for stimulative effect. The operator
must be sure that he is getting direct action on the few
fibers that may remain alive under the usual thick coat-
ing of connective tissue and fat.
Exercises. In general, small and often repeated doses
bring the best results. Like the burning out of a weak
motor, lasting harm may be caused by overdoing. Many
devices for counter-weighting the limb have been used,
thereby giving the patient the early and stimulating ef-
fect of being able to move the limb actively. We have
used a small carriage, consisting of a grooved plat-
form mounted on casters and with a retaining strap.
97
98 ORTHOPEDICS
This is easily made, and by overcoming to a large degree
the friction of even a smooth table surface, will allow
great amplitude of active movement very early in the
treatment.
Let us consider as a typical case a paralyzed arm in
which the adductor muscle group is partially affected, the
abductors of the arm, especially the deltoid, the trapezius
and the supraspinatus have regained their strength but
slightly, the flexors and extensors of the elbow have very
little power remaining, and the muscles of the forearm
and hand are practically powerless.
The following three programs of exercise, preceded by
the application of massage and heat, are suggested as
giving, when used in rotation, a variety, which is of
value in retaining the patient's interest.
PROGRAM I
The patient sitting, affected side toward table, hand strapped
on carriage.
1. "Wide sweep of arm forward and backward.
2. Flexion and extension of the elbow to the side.
3. Wide sweep of arm with one or more attempts to stop and
start again at definite points.
4. Small hand circles, elbow free, done a few times in each
direction.
5. Flexion and extension of the elbow, fixed.
6. Patient leaning far forward, wide sweeps of the arm.,
(The plane of the movement of the arm in relation to the body
is thus changed from horizontal to vertical and valuable help is
given in stretching the adductors.)
7. Forearm fixed, abduction and adduction of the wrist.
INFANTILE PARALYSIS 99
8. Hand turned, ulnar side down, flexion and extension of
the wrist.
9, Patient prone on the table, wide sweep of the arm from
iide to side overhead. (On a narrow table use as wide a move-
ment as possible directly above the head.)
PBOGBAM n. FREE EXERCISES
Patient supine on the table. These exercises may be done
by the affected arm only, by both together or alternately.
Greater variety of neuro-muscular training may be secured by
these different combinations.
1. Raise arm fore upward, carry above head and return.
2. Place hand on hip and return.
3. Carry arm sideward up to head and return.
4. Carry arm across body to opposite side of waist and return.
5. Snap hand to shoulder and return, aided by lifting elbow
sideward if necessary.
6. Carry arm sideward, flex elbow, bringing hand to axilla,
straighten sideward and return,
7. Flex elbow, bringing hand to opposite shoulder and return.
8. Supinate and pronate the forearm. (In this position this
may be a shoulder exercise.)
9. Flex elbow to right angle, supported if necessary and
pronate. (This position eliminates shoulder assistance.)
10. Flex elbow, hand on neck to shorten leverage, extend
shoulder upward and return several times, return hand to side.
PROGRAM m. RESISTIVE EXERCISES
Fingers. 1. A well-fitting kid glove with small rings at the
finger tips, to which are attached very light weights by means
of strings, and used for flexion of fingers singly or together
with the hand supine, the strings running over a wrist roller
100 ORTHOPEDICS
or a row of spools. Pronate the hand for finger extension in
similar manner.
2. Finger flexion machine finger tread-mill.
Wrist. 1. Wrist roller.
2. Supination and pronation machine.
3. Abduction and adduction machine (McKenzie).
With overhead chest weights.
Elbow. 1. With hand encased in glove, if necessary, and at-
tached to overhead pulley handle, flex elbow.
2. With arm at side allow weights to flex elbow as far as
the control of the patient will allow, and extend downward.
Shoulder. 1. From extended arm, carry arm obliquely fore
downward.
2. From extended arm, carry arm side downward.
3. From extended arm, carry arm obliquely back downward.
4. Arm raised sideward at shoulder level, carry forward and
return, carry backward and return.
Without Chest Weights. Patient seated in chair, back to
operator. Operator places hands on tips of shoulders while
patient (1) pulls the shoulder forward, (2) lifts it up, (3)
pushes it backward.
Most of the above exercises can be worked out with
the shoulder or low chest weight, especially with the
patient lying supine, head toward the weights. The
overhead pulley, however, gives the additional advantage
of passive stretching of the stronger, and frequently
shortened, adductor groups. The other, and still more
common, result of infantile paralysis is a partially
paralyzed leg. We will take as our basis a leg in which
all the muscles of the thigh have a fair amount of power
present, the extensors of the foot are considerably weak-
ened, and the flexors are almost powerless.
INFANTILE PARALYSIS 101
PROGRAM I
Patient lying supine.
1. a. Operator grasps the fore part of the foot with one hand,
the heel with the other and passively flexes the toes and the fore
part of the foot.
b. With the right hand grasping the fore part of the foot,
the thumb on the ball, the left hand grasping behind the heel,
the operator vigorously flexes the foot with an attempt at stretch-
ing the gastrocnemius and the calf muscles and, if necessary,
slightly assists the extension. "With the left hand working in
the opposite direction, he overcomes the patient's movement at
the hip, because, in attempting to extend the foot, the patient
will press down with the whole leg, and vice versa.
2. The operator, supporting under the knee with the right
hand, and the left under the ankle, is able to give any needed
amount of assistance to the extension of the leg.
3. Grasping behind the ankle and giving support over the
knee, if necessary, he assists the flexion of the hip with straight
leg.
4. From the same starting position abduction and adduction
are given, the operator carrying the weight of the leg.
5. Deep flexion of the thigh is done with the same assistance.
6. The carriage is placed under the ankle for active abduc-
tion and adduction.
Patient lying on affected side.
1. a. Place the affected ankle on carriage, knee fixed, for active
flexion and extension.
b. With knee bending, flex the thigh acutely.
Patient lying prone.
1. The knee is flexed at right angles and held by operator or
patient for rotation of the thigh.
2. Flexion and extension of the knee.
102 ORTHOPEDICS
3. Overextension of the thigh by backward and upward pull
of the operator.
4. Knee flexed, circling of the foot both ways, which is a
combination of 1 and 2.
There are various tread mills and extension weight
machines, which are of value. Machines for flexion, ex-
tension and circumduction of the ankle all have their
place, if available.
It is taken for granted that the operator will vary
and adjust his exercises exactly in relation to the
strength of each group of the patient's muscles, follow-
ing the general rule that the movements often have to
be entirely passive at first, with a slowly increasing
amount of assistance by the patient, and final develop-
ment into active or even resistive movement. Again I
would caution against too much work. An average of
four to eight repetitions of each exercise in the program
selected are sufficient for each treatment.
Support, especially a brace in the case of the leg, is
almost always essential and when needed should be worn
constantly. The deformities we fear, overextension of
the knee and drop foot, are generally the result of the
neglect of this needed support. Parents often need the
truth driven home to them that it is the brace which car-
ries the child, when to them it appears that the child is
lugging around a heavy extra weight. A late compli-
cation, coming from two to four or even six years after
the disease, is scoliosis, and this must be watched for
from time to time. Indeed, Doctors Hibbs, Farrell and
INFANTILE PARALYSIS . 103
Humphries, from their work in the New York Orthopedic
Hospital, have come to the conclusion that infantile paral-
ysis is the most common single factor in the causation of
scoliosis. Late sequelae in unfavorable or neglected
cases may demand tenotomy or muscle transplantation,
but these operative procedures are not as early resorted
to as heretofore. They should only follow several years
of patient endeavor to secure the fullest results that
may be hoped for from exercise, and, if done, must in turn
be followed by reeducation. Recent rather brilliant re-
sults in apparently hopeless cases have been achieved
by baking for a considerable time in moderate tempera-
ture. One must avoid allowing the monotony of the work
to get one into a rut and to make one overlook the in-
dividual problem incident to each case. Nothing in our
field of work brings richer reward than patient, intelli-
gent work with this distressing condition.
Drop Wrist. This is another common type of paraly-
sis, which may follow fractures of the humerus, or lead
poisoning. It is the paralysis of the extensors of the
wrist and exercises as outlined above are applicable.
Splinting in extension must be maintained constantly.
NEBVE INJUBIES IN WAB
Injuries to the peripheral nerves are very common in
modem warfare because of the extensive lacerations of
the soft tissue caused by many types of projectiles. In
fact the high velocity bullet at mid-range and gas shells
are about the only missiles that do not make this kind of
wound. * * The Orthopedic Treatment of Gunshot In
104 ORTHOPEDICS
juries,'* by Leo Mayer, covers this field in a very satis-
factory manner.
Neurological examinations were made at the Field or
Evacuation Hospital when possible and splints supplied
if the injuries were extensive. It is important to re-
member that all wounds of the soft parts are now splinted
where practicable. I will attempt only briefly to out-
line the diagnosis and treatment of injuries of the most
common type.
Upper Extremity. 1. Brachial plexus injuries are oc-
casioned by axillary or supraclavicular wounds. 2. Cir-
cumflex. The teres minor and deltoid are affected, so
that full abduction of the arm is impossible. 3. Mus-
culocutaneous. Weakness of elbow flexion without areas
of anesthesia occur. 4. Musculospiral. This very com-
mon injury makes it impossible to extend the wrist or
thumb and the proximal phalanges of the fingers are also
affected. The distal phalanges can be extended, supina-
tion and the action of the triceps are weak, and small
areas of anesthesia may be present on the base of the
thumb. 5. Median. Flexion of the fingers and thumb is
absent and there is anesthesia over the first two fingers
and the outer half of the third. To test paralysis of
pronation have the elbow fixed. 6. Ulnar. Fourth and
fifth finger flexion is weak and there is inability to spread
the fingers to the normal extent. The fifth finger and the
inner side of the fourth is anesthetic.
Lower Extremity. 1. Sciatic. There is weakness of
knee flexors and complete paralysis of the foot with
nearly total anesthesia. 2. External popliteal. Dorsal
INFANTILE PARALYSIS 105
flexion and eversion are absent and the dorsum of the
foot and toes is anesthetic. 3. Internal popliteal. Plan-
tar flexion is weak or absent with anesthesia of the sole
of the foot. 4. Musculocutaneous. Foot eversion is weak
and there is anesthesia over dorsum of foot. 5. Anterior
tibial. Dorsal flexion is absent with anesthesia of the
big toe and part of the second toe. 6. Posterior tibial.
Adduction is weakened and toe flexion is absent.
Treatment. Early treatment by splinting in such a
way as to relax the fibers of the affected muscles is essen-
tial. This general rule may be accepted in the case of
ulnar nerve injury because of the danger of contracture,
hence the fingers should be kept straight. Attempt to
bring the severed ends of the nerve into as close approxi-
mation as possible. Plaster, leather or metal may be
used for splinting. In injury to the musculospiral nerve
keep the hand extended. It is well to abduct the thumb
also. The proximal phalanges of the fingers must be
kept extended by the cockup splint.
Chapter VII
THE SPINE DISEASES AND INJURIES
Anatomy. The spine is a flexible column made up
of a series of block-like bones, the vertebrae. There are
thirty-three in the entire column, seven neck or cervical,
twelve dorsal or thoracic, five lower back or lumbar
five fused together for the sacrum and four fused to
form the coccyx. In general, the vertebrsB consist of
two essential portions, the heavy solid body in the front
and the neural arch formed by the two pedicles and two
laminae, with their processes, two transverse, four articu-
lar and one spinous. The bone structure is more dense in
the neural arch than in the body.
The bodies, with their intervertebral, cartilaginous
pads are able to rotate slightly, one upon the other in
what more or less closely approximates the horizontal
plane. The articular processes, however, are placed in
an oblique plane, the superior backward and upward, the
inferior forward and downward in direction. With the
spine erect these articulations act as a check to rotation
between the bodies. The anterior common ligament,
binding the front of the bodies together, is not nearly as
strong as the combined interspinous and supraspinous
ligaments. There is a great difference in the mobility
of the various parts of the spine. We find the most mo-
106
THE SPINE DISEASES AND INJURIES 107
bility between atlas and axis; flexion forward is least
in the dorsal, then cervical, most in lumbar; extension
backward, the same ; rotation is most in the cervical.
Tvhercvlosis of the Spine. ("Pott's disease.") The
spine is one of the most common regions at which the
tubercle bacillus attacks the bony skeleton. One or more
vertebrae may be involved either as a primary or a sec-
ondary focus of infection. The bodies of the vertebrae
are usually the parts first invaded. Points of lowered
resistance caused by trauma are often affected or such a
trauma may bring to light a slowly developing and here-
tofore unsuspected infection and cause its rapid spread.
The "cancellous nature of the bones permit early destruc-
tion with crushing in wherever the infection is exten-
sive. The collapse of the body of one or more vertebrae
makes more prominent the spinous process and forms
on the back the distinctive angular deformity known as
a gibbus. Complete paraplegia from pressure on the
cord may occur. Spinal caries is more frequently found
from the fourth to the fifteenth year.
Symptoms. Knowledge of tuberculosis in the patient
or his family should make us use extreme care to rule
out this condition in the presence of any obscure symp-
toms pointing to the back. Usually they are pain, pro-
tective spasm with resulting rigidity, angular deformity
and the general signs of a chronic infection, although in
early stages this may.not be present. Rigidity alone is
a symptom of great significance and sometimes a suflB-
cient basis for a positive diagnosis. The X-ray should al-
ways be used and will often confirm the diagnosis. It
108 ORTHOPEDICS
is of the utmost importance to differentiate this condi-
tion from scoliosis and kyphosis since the treatment for
tuberculons spine by exercise would do certain injury.
I have seen them exist together, with the postural defects
the more obvious.
Treatment. Pott's disease demands the same consti-
tutional treatment as tuberculous manifestations else-
where in the body. The local treatment consists in fixa-
tion and extension by means of cast, brace, stretcher
frame, or by the operative establishment of immobility,
secured by a bone graft from the tibia implanted into
the split spinous processes and extending one or two
vertebrae above and below the lesion as devised by
Albee of New York. Another successful method is that
of Hibbs, consisting in a partial resection and fusion of
the laminae. This operation has the advantage of mak-
ing but one incision and eliminates the slight promi-
nence of the bone graft. Where the lesion is in the
cervical section an extension of the brace or cast which
will lift up the head is necessary. For example, the
Taylor brace with head support (jury mast) is often
used. Grafts which prevent collapse have been suo-
cessfuly planted into the sacrum. A complication which
necessitates special attention is abscess formation. They
commonly follow the course of the psoas muscle, and
point in the inner side of the thigh, but are subject to a
wide variation and may point in almost any direction
from the seat of the lesion. Aspiration under aseptio
precautions is sometimes advisable. Sinuses already
formed should be injected with Beck's bismuth paste.
THE SPINE DISEASES AND INJURIES 109
They should be carefully dressed to prevent mixed in-
fection and will usually clear up when proper measures
are instituted at the seat of the original lesion.
TRAUMATIC INJURIES
Strain and Sprain. Prolonged carrying of heavy
weights when the patient is not in proper condition may
lead to back strain. An example of this is the heavy
marching order on the part of the recruit not yet thor-
oughly hardened. Weight lifting in the stooping posture
is the common cause of lower back strains. Sudden
twisting or falls upon the back or the awkward landing
after jumping, may lead to quite severe sprains of any
of the various ligaments.
Treatment by means of heat, massage, rest, and sup-
port is indicated.
In sacro-iliac sprain the following strapping will be
found most serviceable: The patient lying prone, the
surgeon fixes the strap, which should be the full width of
the roller, 3 to 5 inches in front of the anterior superior
spine on the further side of the patient. The patient
then rolls slowly away from the surgeon, who applies
the strap tightly obliquely upward, ending just below the
twelfth rib of the opposite side. The procedure is then
repeated in the reverse direction, the two, broad, snugly
fitting straps crossing over the sacrum. They may be
reinforced by a short vertical strap of the same width
over the sacrum and one or two lumbar vertebrae. Most
corsets or belts which fasten in front aggravate the con-
no ORTHOPEDICS
dition because their pull tends to open the saoro-iliao
joints.
Bruises. Bruises of the muscles and ligaments along
the spine show, beside the swelling and discoloration
which may be present, a localized tenderness on one side
of the spine. The spinous processes should not be tender
in this injury.
Fractures and Dislocations. Spinal fractures are rare.
Cervical Region. This region, because of its mobility,
is prone to dislocations, but fractures do occur. Slight
lesions only need treatment, as a fatal outcome is almost
certain in severe injury. Dislocation of the atlas an-
teriorly on the axis is sometimes seen. Slight displace-
ment, if associated with fracture of the odontoid process,
may not be fatal. In this lesion the short spine of the
,axis may be palpated. The head is bent forward. Slight
lateral dislocation at this joint, or between the other
<jervical vertebrae, is not uncommon and gives no other
symptoms than slight pain and rigidity of the neck.
Treatment. After anesthesia, gentle hyperextension
maintained by a jury mast is necessary. In lateral dis-
placements tilt the head toward the opposite side, in-
creasing the deformity, but unlocking the facets; turn
the head toward the deformity to raise the caught facet
and then re-turn the head to a correct position.
The third, fourth, or fifth cervical vertebrae may be
fractured or partially dislocated by blows or falls on the
head. Such injuries are reduced as described, under
anesthesia, if required. When removal of the patient is
necessary in any of the above injuries some means of ex-
THE SPINE DISEASES AND INJURIES 111
tension is essential. A temporary collar of folded stiff
paper, plaster or other stiff material will attain this re-
sult.
Dorsal Region. In the dorsal vertebrae the bodies or
laminae are seldom fractured except in fatal accidents.
The spinous processes, however, are subject to fracture.
The symptoms are sharp pain, crepitus, and abnormal
mobility on palpation of the spinous process. Extravasa-
tion of blood in the tissues may be noticed. Deviation
of a single spinous process, which may be gently pressed
back to its normal position, and the localization of pain
close to the skin are other prominent symptoms. The
examination should be supplemented and the diagnosis
confirmed by the X-ray. In the lower cervical and upper
dorsal regions a support transferring the weight to the
pelvis is efficient and permits of the patient getting about
fairly early. In lower dorsal injuries this complete re-
lief from weight bearing is difficult to attain. At least
two months in the recumbent position is required for
absolute safety.
Lumbar Region. The mobility of this region and the
fact that it is unprotected by bony structures, as the dor-
sal region is, subject it to injury. Dislocation is ex-
tremely rare and even in fracture of the bodies we do not
as a rule get marked displacement. Fatal outcome of
such injuries is rare since they are below the level of the
cord. Careful examination is required as it is easy td
overlook fracture in this region. Any change in the nor-
mal lumbar curve is suspicious. X-ray should be used
in diagnosis whenever possible. The appearance of lum-
112 ORTHOPEDICS
bar deformity, particularly backward displacement, re-
quires extension on the stretcher frame. As is the case
with lower dorsal fracture, it is impossible to completely
relieve weight bearing. Treatment in the horizontal po-
sition must be continued six to ten weeks.
Partial dislocation forward of the fifth lumbar verte-
bra on the sacrum is becoming increasingly common and
often follows relaxation of the sacro-lum bar ligament.
This is due to the abnormal obliquity of the pelvis, which
occurs in lordosis, and which is often associated with the
wearing of high heels. This is a common cause of back-
ache and it is most difficult to obtain fixation by means
of a brace. Treatment by orthopedic gymnastics is not
satisfactory since the required muscle leverage is lacking.
Fixation by bone graft is often the only permanent means
of cure.
Partial sacro-iliac dislocations may in like manner re-
quire bony fixation if the lesion is an advanced one.
Treatment of mild types of this condition have been de-
scribed under the topic of sprain.
Penetrating Wounds. Wounds by shrapnel, bayonets
and bullets are common in the spine. The bodies and the
sacrum do not splinter to any extent. From the spinous
process, pedicles or laminae splinters or chips of bone
may be driven into the cord. The occurrence of paraly-
sis, which by its type will aid in localizing the injury,
calls for operative interference. Use the X-ray for diag-
nosis and reduce probing to a minimum. Infected wounds
should be treated by Carrel or other approved methods
and the fixation should be prolonged.
Chapteb Vlii
CURVATURE OF THE SPINE
Kyphosis. This is an abnormal increase in the dorsal
curve of the spine accompanied by a forward position of
the shoulders and head. With accompanied lordosis it
gives us a picture known as fatigue slump. There is a
type of rounded back, the appearance of which is due to
a heavy bed of muscle under and over the scapulae. The
pronounced development of the muscles beneath the
scapulae, but more especially of the supra- and infra-
spinatus, the rhomboids, the trapezius, teres major and
latissimus dorsi, found particularly in heavy-set athletes,
rounds out the back. This heavy type of muscle is often
found in weight-lifters, wrestlers, football players and
apparatus and gymnastic team men, and we find the same
heavy bed of muscles on the chest. The need for keeping
such a build in mind is apparent at once in considering
the relationship between this condition and corrective
gymnastics. Exercises would of course be superfluous,
since there is no weakness of the upper back groups and
no generalized weakness.
Obviously an incorrect posture of head and shoulders
is concomitant with this condition and when they do
occur together the emphasis should be laid simply on the
reeducation of the muscle sense to correct posture. As
113
114 ORTHOPEDICS
shown clearly in the studies made and charts worked out
by the American Posture League, the proper carriage
without exaggeration, of the head erect, the shoulders
back and the abdomen well retracted is that position
which throws the least strain upon those groups of mus-
cles whose action maintains the upright posture. With
each small increase in deviation from this normal pos-
ture we are subject to a very great increase in the effort
necessary to stand erect. There is, therefore, due to the
weakening effect of such unnatural effort, a tendency to
further slumping. For instance, this fatigue position
into which a person has fallen during the weakness of a
convalescence may of itself so increase the strain of
standing correctly as often to make it impossible for him
without special treatment to reassume his former normal
posture even after complete return to vigor. The con-
ditions once assumed tend to become habitual, and due
to a gradually modified muscle sense, may be absolutely
unconscious on the part of the patient.
The two great factors that determine the rapidity and
the amount of increase of any postural defect are the
strain to which the tissues of the body are subject and
their resistance to that strain as determined by their
state of health and development. In estimating the
amount of strain we have to consider duration in rela-
tion to periods of rest, as well as intensity and amount.
Causes. As indicated above, the causes of this type
of faulty posture fall naturally into two groups. First,
where the tissues of the body are weakened because of
too rapid growth, illness, faulty metabolism, impaired
CURVATURE OF THE SPINE 115
mental development, overweight. Children handicapped
in any of these ways are affected quickly by undue strain
and we should never lose sight of the fact that the aver-
age burden may for them be too great. The second cause
is where normal children have too great a burden placed
upon them. Among the common strains to which child-
hood is subjected, habitually assumed faulty attitudes in
school, at home or at work are the most common. The
hanging of clothing from the shoulders where the weight
falls, as it usually does, far out towards the tips, is an-
other cause for slumping forward. Defects of vision and
hearing and excessive abdominal weight are also fre-
quent causes.
Symptoms. The earliest symptoms shown are for-
ward position of the head and the prominence of the
lower angles of the scapulae, followed later by a rolling
outward of their entire inner borders, with stretching of
the rhomboid groups and a forward position of the shoul-
der tips. Up to this point there may be no noticeable
involvement of the spine. This slight amount of stoop
is not included in kyphosis by some authors. Some col-
lege medical examiners, who do include this degree of
faulty posture under the term of kyphosis, have reported
from sixty to eighty per cent of their students as in this
class. The next degree involves the spine and it be-
comes increasingly difficult for the patient on command
to assume the normal posture. In fact, it is often alto-
gether impossible for him. There is a growing tendency
for the deformity to become fixed and the spine less flexi-
116 OBTHOPEDICS
ble. A structural shortening of the pectoral group is
found in nearly all the marked cases.
Treatment. By this time the necessity for the early
institution of the proper treatment, before the condition
has progressed far in time or degree, must be evident
to the reader. Our problem is not a simple one. It in-
cludes, of course, the removal of the cause, if possible, if
it be of the type we have included under undue strain.
The general health of the patient must be built up and
especial emphasis laid upon this procedure where we
have determined the cause to be subnormal strength due
to any of the conditions mentioned in that group. ' Our
corrective exercises are aimed at the particular group
of muscles whose relaxed condition allows the faulty at-
titude, here largely the trapezius, rhomboids, supra-
spinatus, and the stretching out of their physiological op-
ponents, with their tendency to contracture, in this case
the pectoralis major and minor especially.
There is probably no type of deformity where the use
of braces is so much abused as in this case. It is well
to remind the reader again that it is only by proper use
that muscles grow strong, and if the back muscles are
weak and relaxed and the patient allows his shoulders to
be pulled forward by the stronger pectorals, a brace
would but make a bad matter worse. It would allow the
upper back muscles to relax completely and to perform
a very small proportion of their normal amount of work.
It is evident that it is their increased development and
not their relaxation which we desire. These same prin-
ciples apply to all braces for the correction of faulty pos-
CURVATURE OF THE SPINE 117
ture. They are as a class not only useless but often do
great harm. Their only justifiable use is to prevent
tissue relaxation during some temporary weakness and
should then be coupled with definite effort to strengthen
the affected parts.
The special fault to be found with shoulder braces as
a class is that they exert their counter pressure against
the mobile lumbar spine and tend to produce lordosis. It
is not unusual for children wearing such braces to appear
at the dispensary with their shoulders held back but their
heads thrust forward and a very pronounced degree of
lordosis developed.
EXERCISES
1. Comer exercises. Child facing the comer of the room
about three feet in front of it places the hands, elbow high,
against the wall about a foot on either side of the corner and
the same distance below the shoulders. The body is lowered
forward by bending elbows, keeping the chin and abdomen re-
tracted, then pushed backward to straight arm. The teacher
standing behind resists the push by exerting counter pressure
with the hands between the scapulae.
2. Arm shoulder groups using three counts.
(a) 1. Arms forward raise. 2. Sharply sideward carry. 3.
Sideward lower keeping shoulders retracted.
(b) 1. Arms forward raise. 2. Arms sharply forward bend.
3. Sideward lower keeping shoulders firmly back.
(c) 1. Arms forward raise. 2. Obliquely side upward raise.
3. Sideward lower.
3. Knee bending at stall bars. Patient stands back to stall
bars, grasps behind shoulders, then keeping head, shoulders and
hips against the bars, does deep knee bend.
118 ORTHOPEDICS
4. Hand suspension spine twisting.
5. Pectoral stretching supine on plinth or narrow bench,
neck firm, counter pressure downward on elbows.
6. Swimming arms forward bend, lower trunk forward, carrj
arms fore upward and slowly side downward in imitation of
breast stroke.
7. Hand suspension with counter pressure between shoulder
blades.
8. Arm rotation outward, forcing shoulders back.
9. Patient sitting on chair or bench, with neck firm. Teacher
stands behind, knee, padded if necessary, between shoulder
blades, grasps shoulders or upper arm, fingers in front, thumbs
in back and passively stretches the pectorals.
10. Mirror ^for reeducation of muscle sense with the aid of
sight to proper posture.
11. Floor hang forward. Patient stands in back of slanting
ladder grasping round, shoulder high, arms length in front.
"Without moving feet body sways forward.
12. Wands. Raise arms upward in line with shoulders.
Marching head erect with wand behind shoulders. Thrusting
upward, lowering behind shoulders, trunk lowering forward.
Exercises 1, 2, 6, 7, 8, 11, and 12 are given particularly
for the strengthening of the dorsal muscles.
Exercises 3, 5, 9 and 11 aim at the stretching of the
pectoral muscles.
For attaining general flexibility, exercise 4 is espe-
cially valuable.
Exercises 6 and 11 should not be used in cases where
lordosis also occurs, as their action would tend to in-
crease the lumbar curve.
The mirror is of particular value in training muscle
CURVATURE OF THE SPINE 119
sense which must be reeducated before the patient will
be able to retain a correct posture.
Whether or not all these exercises, which should be
done four times each, are included in an ideal program,
it must be remembered that in the development of tone
and reeducation of muscle sense bodily tone must be
raised, the weakened groups of muscles must be exer-
cised, the contracted muscles must be stretched and gen-
eral flexibility must be attained so that definite exercises
for each of these aims must be included in every pro-
gram.
Lordosis. Lordosis is an abnormal curve forward in
the lumbar spine.
Occurrence. Slight degrees of lordosis are extremely
common, but such an amount as will call for treatment is
rather rare.
Causes. All the etiological factors mentioned for
kyphosis may be secondary causes of this condition since
lordosis often is secondary to and compensating for
kyphosis. Such compensation is necessary for the rea-
son that, with the head and shoulders forward, the center
of weight transmission would fall too far forward in the
lumbar region. The spine, therefore, adjusts itself by
increasing the lumbar curve so as to reestablish the
transmission of weight in the normal plane.
Among the primary causes are : 1. High heels, which
increase the inclination of the pelvis, thereby tilting for-
ward the lower lumbar vertebrae also and making an
increased curve necessary. 2. Excessive abdominal
weight such as the deposition of a large amount of fat
\
120 ORTHOPEDICS
in the abdominal wall. Pregnancy may be a temporary
factor. Poor or exaggerated posture may also bring
about this condition.
Sequeke. The superincumbent weight of the body,
the greater part of which is borne by the lumbar verte-
brae, tends greatly to increase this condition when once
it has been established. In addition the increased in-
clination of the pelvis changes a section of the lower
front abdominal wall from being merely a retaining wall
to a weight bearing floor of the abdominal cavity. The
abdominal contents tend to follow the relaxed wall and
their ligaments exert an increased pull forward and
downward upon the lumbar spine. This condition in two
ways again exemplifies the fact that a structural de-
formity once established tends to increase in degree.
Treatment. Braces are useless unless they take their
fixation on the more immovable lower dorsal vertebrae
and sacrum and are coupled with exercise. If the cause
is indirectly due to kyphosis, that condition should be
treated at the same time. General conditioning to re-
move the abdominal weight must be undertaken and the
heels should be lowered when these evils are a part
of the cause.
EXERCISES
1. Long sitting. (Legs extended forward on table or floor,
knees straight.) Hold several minutes.
2. Supine lying.
(a) Alternate knee bending upward.
(b) Alternate leg raising forward.
CURVATURE OF THE SPINE 121
(c) Stride seat on plinth or narrow bench. Raise wands
fore upward overhead and raise legs to long
sitting position, lowering wand behind shoul-
ders and return to starting position.
3. Hand suspension.
Alternate knee raising.
4. Long sitting.
Arms thrusting upward against counter-pressure.
5. Hand suspension with both knee raising. Later both leg
raising, knees straight.
6. Supine lying, feet fixed sitting up and returning to lying.
This last exercise can be made increasingly severe accord-
ing to the arm position. It is the easiest by extending arms
over head and flinging them sharply with raising of the body.
Next, with arms beside the body, then extended sideward or
folded, and hardest, with arms extended over head without fling-
ing with the body raising.
7. Supine lying.
(a) Bend both knees upward.
(b) Raise both legs upward.
(c) Flex and extend knees alternately in imitation of
bicycle pedaling.
8. Long sitting retain several minutes.
Numbers 1, 2, 3, 4 and 8 stretch the erector spinae
muscles.
The others strengthen the abdominal group of mus-
cles, the object of which is to bring the sternum and the
pubis closer together, decreasing the inclination of the
pelvis.
Scoliosis Rotary Lateral Curvature. One author has
stated that ''lateral curvature is the most diflficult and
subtle part of orthopedic surgery," and a survey of the
122 ORTHOPEDICS
literature would certainly seem to confirm this state-
ment. It is especially confused in regard to the causes
of rotation and the direction in which it takes place.
A good deal of valuable research on this subject has
been done by Lovett of Boston, Young of Philadelphia,
and others. Lovett especially, in his excellent book,
"Lateral Curvature of the Spine and Round Shoulders,"
devotes several chapters to the working out of the prob-
lem of rotation on the living model and the cadaver. He
bases his conclusions, that the bodies rotate toward the
concavity on his experiments in functional lateral trunk
bending on the part of the model and on the torso of the
cadaver, and assumes that this applies equally to func-
tional lateral curvature. He also states in common with
other authors, that the apparent curve as shown by the
marked spines is no index of the latitude of deviation that
may be present in the bodies that the apparent curve
may be less than the real curve. Most investigators be-
lieve that the rotation is a torsion or twisting due to
superincumbent weight. Following the law that where
those in the center of a column of block-like bodies are
displaced so that the center of gravity falls nearer the
periphery of some and weight or pressure is exerted on
this column, those blocks displaced will twist upon their
vertical axis, the amount of turning being in proportion
to the amount of displacement. That the spine follows
this rule is conclusively demonstrated by Young in his
text-book. The bodies of the vertebras rotate toward the
convexity of the curve, turning the spines back toward
CURVATURE OF THE SPINE 123
the mid line, thus making the apparent curve less than the
real curve.
Many orthopedists believe that the structural curves
are always associated with softening of bone, and that
normal tissue may not be deformed. Recent operative
procedures for the correction of scoliosis demonstrate
that the bodies of the vertebrae rotate toward the con-
vexity, as I have stated, and that bone deformity, espe-
cially wedge shaped vertebraB, is not by any means al-
ways found in rigid curves, but that these curves may
readily be straightened out, once the muscles have been
dissected away and that they are entirely responsible for
the apparently fixed condition of the curve. This is a
still further confirmation of the fact already stated that
muscles, which are given slack, tend slowly but surely to
a definite structural shortening, that may become ex-
tremely resistant to corrective measures.
Occurrence. Percentages given for this defect differ
widely, and the acceptance of very slight degrees of
scoliosis depends largely on the personal equation of the
examiner. Seventeen per cent for girls, ten per cent for
boys is probably a conservative estimate of the preva-
lence of this condition.
Classification. From the standpoint of the condition
of the tissues involved scoliosis may be divided into func-
tional, postural and flexible, and into rigid, fixed, struc-
tural or organic. From the standpoint of the appearance
of the curve, or curves, we differentiate the single, sim-
ple, total or "C shaped curves from the compound,
double (sometimes triple) or **S'* shaped curves. The
124 ORTHOPEDICS
above classifications are not interchangeable for, while it
is perfectly true that most curves in the beginning are
both single and flexible, single curves may become fixed,
or double curves remain flexible.
Causes. It has been stated that ''school-rooms are
factories of scoliosis." An exact knowledge of the me-
chanics of proper school sitting is necessary if we are
to decrease this defect. The following requirements
have been found most satisfactory: (a) Height of seat;
feet should rest lightly on the floor, knees bent at right
angles, (b) Seat should slope slightly back, three-eighths
of an inch, (c) The length of the seat should be two-
thirds the length of the thigh, (d) The width should be
at least that of the hips, (e) The back should slope back-
ward about one inch in twelve from the vertical, (f)
The edge of the desk should be in a straight line over
the edge of the chair, (g) The height should be such
that the forearm rests easily with elbows at right angles,
(h) The desk should slope back from 10 to 15 degrees;
30 degrees would be best for seeing, but the books would
slide at this angle, (i) Pupils should sit back from the
desk so that about two-thirds of the forearm rests on
it.
The large easy chair, often set aside for the family's
young hopeful, in which, because of its size, he is able to
curl up and readily forms a postural habit, which con-
tinued through the years may markedly affect the spine,
is also a cause to be considered. The habitual carrying
of all burdens on one side, for example, newspaper bags,
bundles of school books, hods of coal, etc., is another
CURVATURE OF THE SPINE 127
common cause. It is remarkable how soon children form
a habit of carrying a given burden in the same way, and
many of them are continuously carried for a number of
years. Shortness of one leg is a frequent cause. The
careful following up of the 1916 infantile paralysis cases
and careful comparison with earlier epidemics has led
many orthopedic surgeons to the conclusions that this
disease is among the very common causes for scoliosis,
the pull of the muscles on the less affected side being re-
sponsible.
Diagnosis. The main reliance is placed on the five fol-
lowing symptoms: 1. Unequal distances of the inner
border of the scapulas from the spine; it is less on the
convex side in a dorsal curve. 2. The rhomboid shaped
space between the arm and the body, sometimes called
the arm waist angle, is less on the side of the curve. 3^
Uneven hips and shoulders ; the shoulder tends to be high
on the side of the dorsal curve. The hip on the side of
the curve in the lumbar region is made prominent. This
is often mistakenly called a high hip. 4. The marked
spines show the direction but not the degree to which
the vertebras are involved. 5. Prominence of one side of
the back is brought out by trunk bending forward, the
arms hanging loosely and evenly, the Adams' position.
Convexity caused by the prominence of the ribs is on the
side of the curve in whatever region it may be, but it is
less apparent in the lumbar region. On this sign alone
diagnosis of functional curvature is justifiable.
Treatment. Preventative treatment consists in the
study and proper regulation of all habitual postures,
128 ORTHOPEDICS
keeping in mind how early such habits are fixed, and the
importance of attacking the problem before faulty atti-
tude is established Postural habits are corrected by fol-
lowing the rules which apply to the overcoming of any
other habit, physical, mental, or moral. Briefly they are :
1. To create a clear cut picture in the child's mind of the
correct posture from which he habitually deviates in
work, rest or play with reasons if necessary. 2. Punish-
ment, if necessary, should follow immediately and should
logically fit the misdemeanor. Here, then, it should be
postural in type and, if possible, over-corrective in char-
acter. For instance, a child with a left total curvature,
who is told to carry weights on the left side and has been
given the reasons, is discovered carrying a weight on the
wrong side. He should be made at once and under super-
vision to do some work carrying the weight on the proper
side. 3. Allow no exceptions to occur. Relatives, teacher,
physical director, etc., should all cooperate to see to it
that the child is reminded of every single slip. Patience,
long continued, may prevent serious deformity. Proper
food and rest are all-important for the normal ossifica-
tion of the bones and defects of vision and hearing or the
shortness of one leg, or any other contributing cause
should be remedied.
Not only will general strength and development help
somewhat in postponing the onset of a scoliosis, but they
are elements of the tissue resistance which delays the
stage of structural deformity of the muscles. Local
treatment consists of casts or braces and exercises.
Operations. Bone fusions or graft operations, which
CURVATURE OF THE SPINE 129
have recently been done with what gives promise of be-
ing most brilliant results in selected cases, leave the pa-
tient with a stiffened but straight spine in the affected
region. This rigidity is not especially an undesirable
feature since these curves are all quite rigid in their
deformed position.
Casts. Casts may be permanent or removable. Great-
er correction and counter pressure is obtained by the
permanent cast, worn usually for about three months.
During this time the spine tends to increase its rigidity,
musculature is weakened and the general health often
slightly impaired. The removable type gives some sup-
port, allows an opportunity for exercising, but cannot be
applied to give as great correction. Casts may be put on
in the sitting, standing, lying or suspended posture.
When adjusted to the patient lying supine one of two
methods is employed. First, that advocated by Abbott,
Adams, Lovett, and Bradford with the spine flexed, and
second, the method advocated by Whitman, Schultess and
Bucholz with the spine in hyperextension. That two
exactly opposite positions of the spine should be used
with rather satisfactory results in both cases seems at
first difficult to explain. The principles involved are
these : The Abbott method aims at unlocking the articular
facets, thereby unlocking the vertebrae and making re-
rotation possible. Since the first effect of such unlocking
of the articulations is to increase the rotation, the ap-
parent curve is of course less, and this fact has misled
some men into thinking that the spine is actually straight
in this position. It must be remembered that a consid-
130 ORTHOPEDICS
erable amount of the correction or overcorrection force
obtained by this method must be expended on merely re-
rotating the vertebrae to their former position before
any net gain can be secured.
The other method, that of hyperextension, aims at re-
lieving the weight bearing rotary strain upon the bodies
by shifting it backward upon the posterior part of the
vertebral column. This position of course would greatly
aid in the rerotation of the vertebra bodies, but neces-
sarily more tightly locks the articular processes, which
in itself prevents rotation. So that any corrective effect
must act on the column as a whole. It is, not yet certain
which is the better way. The rather brilliant results re-
ported by Abbott have not as a rule been obtained by
those imitating him.
The postural type of scoliosis very seldom requires a
cast. In fact, where constant exercise under supervision
is available there is a tendency now to depend more than
ever on active exercise. In any case a period of exercise
for the improvement of muscle tone and greater flexi-
bility should be interposed between the casts.
Various types of braces and corsets widely advertised
usually do more harm than good. Successful treatment
of scoliosis is not accomplished by the mail order plan.
In all cases with marked softness of bone and those of
rapid development, casts should always be used. In situ-
ations where exercises under good supervision are not
available main reliance must be placed on casts.
Exercises. Various corrective positions, using the
body weight to secure counter pressure, on various types
CURVATURE OF THE SPINE 131
of archaic apparatus now collecting dust in the attics of
many orthopedic institutions were formerly greatly re-
lied upon. A glance through the older text-books will
reveal the wide variety of this type of armamentarium.
Active exercise on simple apparatus supplemented by
counter pressure on the part of the operator is now used
almost exclusively.
PROGRAMS OF EXERCISIS
I
Left Total Curve.
1. Comer exercise. Technic as described
for kyphosis except counter pressure by
operator with left hand on the greatest con-
vexity on the left side and enough on the
right hip to prevent the patient twisting
to the right.
2. Stretch walk with self correction.
Self correction must be worked out in each
individual case. Here it would be with the
right arm stretched up, hand resting
lightly on the head, left palm pressing
against the side as high and as far back as the patient can place
it, the patient walking a few steps usually on the toes with active
attempt to stretch the spine. Frequent periods of relaxation and
short periods of intense effort should be insisted upon.
3. Hand suspension, spine twisting. Hanging on horizontal
bar or rings and twisting as far as possible right and left.
4. Trunk bending left, hips fixed, self correction as above.
5. Mirror. Reeducate muscle sense through the eye. Assist
patient to assume his best possible posture. Have him walk
around the room, return to mirror and correct any slump that
has occurred.
132 ORTHOPEDICS
6. Hanging by right arm, back to stall bar or slanting ladder^
left heel supported, right leg hanging,
7. Trunk forward bending or lowering, hips fixed, and rais-
ing against counter pressure as in 1.
8. Spring sitting. Sitting on right side of stool body in-
clined forward, right arm reaching actively toward wall or
stall bars, right leg stretched backward. Work arm and leg
toward the left, actively stretching the right side. Retain about
half a minute.
9. Hand suspension, counter pressure. Hang from rings or
bar, operator pushing patient forward, counter pressure as in 1.
10. Prone lying, feet strapped, trunk raising backward, self
correction as in 2.
11. Stretching for head plate.
12. Floor hang, legs left. Patient grasps horizontal bar, stall
bar or rings about shoulder high and hangs down to straight
arm with the feet well out to the left.
13. Stretch walk, balancing weight on the head.
14. Supine hook lying spine stretching. Patient on table,
right knee over the end, the right arm extended upward and
grasped by the operator who stretches the right side.
15. Creeping in a circle to the left, reaching well forward
with the right arm.
16. Prone leg lying, trunk raising. Patient lying prone with
waist at end of table, feet fixed, trunk flexed over end of table
and raised upward to fullest possible extension, self correction
as in 2. A severe type of exercise for later progression.
17. Sayre suspension. The addition of hip harness to fix
pelvis, patient on stool, is very efficacious.
18. Strap table pelvis and shoulders fixed to the left, one
or two central straps fixed to the right, running over the back,
under the body, from which end traction is exerted toward the
right and the straps fixed maintain ten minutes.
A selection of eight or ten out of the above group, being
CURVATURE OF THE SPINE 133
sure to pick at least two of each group and reserving the others
for the varying of the program later, would be sufficient.
We must stretch the muscles on the concave side. This is
done by exercises 2, 4, 6, 8, 11, 12, 14, 15, 16.
To increase flexibility exercises, 3, 13, and 16 are good.
Bilateral strengthening of the back is accomplished by ex-
ercises 1, 10, and 16.
Rerotation by counter pressure. Pressure on the convexity,
on the ribs is transmitted to the side of the vertebral body and
rerotates it. All the exercises in which counter pressure is
used, exercises 1, 7, 9, and 18 do this.
Reeducation of muscle sense employs particularly exercises
2, 5, and 13. Note. Reverse each position for right total curve.
Right Dorsal Left Lumbar Curve.
1. Comer counter pressure on right dorsal, left lumbar con-
vexities.
2. Stretch walk with self correction. Right hand on pos-
terior axilla, left at the waist line.
3. Hand suspension, spine twisting.
4. Trunk bending sideward toward principal curve.
5. Mirror.
6. Hanging by left arm at stall bar or slanting ladder, left
heel supported, right leg hanging.
7. Trunk lowering forward, counter pressure as in 1.
8. Spring sitting, left arm up, right leg back.
9. Prone lying, feet strapped, trunk raising backward, self
correction as in 2.
10. Stretching for head plate.
11. Stretch walk, balance weight on head.
12. Supine hook lying, spine stretching, right leg over end of
table, traction on left arm.
134 ORTHOPEDICS
13. Prone leg lying, trunk raising, self correction as in 2.
14. Creeping with left arm leading as much as possible and
slightly -dragging the right leg, wide movements of shoulders and
pelvis giving some correction and increased mobility.
15. Sayre's suspension.
16. Strap table ^shoulders fixed to the right, hips to the left,
dorsal strap pulled and fixed to the left from below, lumbar
strap pulled and fixed to the right from below.
To increase flexibility 3, 11, 14.
Bilateral strengthening 1, 9, 13, 15.
Rerotation by 1, 7, 8, 16.
Reeducation 2, 5, 11.
Note. Reverse all positions for left dorsal right lumbar curve.
In both the above programs there should be progression in
the severity of the exercises selected and the number of repe-
titions which might be increased or varied from four to ten.
Chaptbb IX
JOINT INJURIES AND ARTHRITIS
'Anatomy. Joints are formed by the approximation of
two or more bones, whose surfaces are usually covered
with articular cartilage, then with synovial membrane,
moistened and lubricated in the healthy state by synovial
fluid. In most movable joints, surrounding these struc-
tures is a sleeve-like capsular ligament, reinforced in cer-
tain portions where the strain is greatest. Closely asso-
ciated with many joints and relieving the friction of
tendons upon each other and the bone, are found closed,
membranous sacks called bursae, which are partially
filled with synovial fluid. The crucial ligaments of the
knee and ligamentum teres of the hip directly bind the
bones together. Any or all of these structures may be
acutely or chronically injured by trauma, toxins, or di-
rect bacterial action. A common type of trauma is slight
and long continued faulty posture.
Classification. Joints are classified as immovable and
movable, which include sliding, hinge, pivotal, saddle,
condyloid and ball and socket. With the first, as exem-
plified by the sutures of the skull, we are not here con-
cerned.
Sprains and Dislocations Traumatic Lesions. A
ftraijLis often described as the result of the application
135
136 ORTHOPEDICS
of force, abnormal in degree or direction, which does not
result in an anatomical lesion of any of the structures of
the joint. It would, therefore, at most, but temporarily
weaken the function of the joint, and would be treated, if
necessary, by the means to be described under sprain.
\^ A s prai n is a partial but immediately replaced disloca-
J tion, during the process of which, however brief in time,
there is an actual tearing or other injury to the tissues
^ making up the joint. ^ Tha symptoms are those of strain,
but considerably aggravated, and include pain, swelling,
sometimes slight hemorrhage and more or less limitation
of function. The swelling is usually that of increased
synovial fluid and lymph within the joint, bursas or sur-
rounding tissues, nature's object being to cushion the
injured tissues with a water jacket and so to prevent
further injury. Four undesirable results may follow here
and demand our attention. First, an excess of fluid with-
in the joint, as in the case of the knee, may so force the
bones apart as to make them unstable in a direction in
which, in the normal state, because of the bone forma-
tion, they are not apt to slip. In the joint named, the
tendency to lateral instability is the case in point. Sec-
ond, a large increase of fluid within the bursas or tissues
may make these supports of the joint boggy and unse-
cure. When the fluid is finally absorbed the ligaments
tend to remain relaxed, as a result of long continued
stretching. Third, there is a tendency, particularly in
an unused joint, for this fluid to become gummy and
gelatinous. This may lead to the formation of more solid
bodies, the so-called rice kernels, within the joint. The
JOINT INJURIES AND ARTHRITIS 137
frequent reinjury, which so often accompanies untreated
cases, with retarded recovery, may lead to a thickened,
doughy synovial membrane, which, equally with the
coagulated bodies just mentioned, may mechanically in-
terfere with the normal range of movement, most com-
__j]aaaly^f ound in the knee.
Finally, comes the formation of scar tissue or even
bone ankylosis by reinjury. This reinjury is most apt
to occur during the healing process unless, while under-
going repair, the tissue is protected from any movement
or position simulating that which brought about the orig-
inal lesion.
In regard to dislocations, generalizations only are here
in order. For detail in regard to each of the possible
dislocations of the various joints the reader is referred
to the section on fractures and dislocations and to the
excellent texts of Cotton, Stimson, Preston, Jones and
others.
Dislocation is a complete, temporary or permanent
change in the relationship of the bones comprising the
joint. The surrounding ligaments are always torn.
Often through the rent one or more of the bones ap-
pear.
Diagnosis. Where the bony landmarks are all in nor-
mal positions, where the swelling and tenderness are on
one side of a joint, and where gentle manipulation can
be performed throughout nearly its normal range and
direction but a given movement elicits more pain than
other movements, in that joint we may assume that we
are dealing with a sprain.
138 ORTHOPEDICS
Where there is malposition of the bony landmarks,
considerable swelling, only a moderate amount of hem-
orrhage, where the pain is diffused about the joint and
the movement greatly limited in amount or direction,
the probabilities are that we have a dislocation.
Where the greatest pain is localized above or below the
joint, the hemorrhage marked, the bony landmarks
changed in their relations and, except in impacted cases,
the motion increased and not in the joint, a diagnosis of
fracture is justifiable. When there is probability of the
presence of either dislocation or fracture, the X-ray
should always be resorted to if possible.
Treatment. With a clear-cut impression of the se-
riou"s"consequences that may follow untreated cases of
sprain, it is yet just as important to remember that many
patients suffer from overtreatment, or, better, over-
protection, because the fundamental and best of all types
of treatment, within reasonable limits, is use. This is
shown by the fact that animals use lightly but constantly
such an injured joint, and the rapidity with which it
usually heals is enlightening. Hemorrhage in this type
of injury, though usually slight, must be considered.
When internal bleeding has ceased, the use of the joint,
where hemorrhage had occurred, is desired. It will aid
in preventicg the clotting of blood in the tissues and in
quickening its absorption. Use must be differentiated
from overuse or resprain, and can be attained best by
means of light or partial support, or complete preven-
tion from movement in an undesired direction or degree.
To cite again the knee joint, this might be accomplished
JOINT INJURIES AND ARTHRITIS 139
by the use of a simple hinge brace, locked against over-
extension and preventing any twisting or lateral devia-
tion. In the ankle the common injury to the external
lateral ligament can be properly supported by reversing
a flat foot strapping, omitting the plantar straps, and
weaving in a few cross straps. If seen at once an ap-
plication of cold generally prevents excessive swelling.
In all the many and valued uses for the various types of
baking there is none in which the results are more grati-
fying than in its application to these cases. Massage
is also of great value and should, if possible, be used in
combination with baking.
Dislocations are reset at once and treated as severer
sprains with emphasis on fixation and protection. In dis-
locations or injuries involving severe tears of tissue the
tendency to increase the amount of adhesion must be
carefully guarded against. Too early and too violent
movement of the joint will tear through the new formed
tissue, increase the inflammation and the amount of
fibrous exudate. Pain is our main guide. It is safe to
move the joint slowly as far as we can without eliciting
severe pain. Massage is of great help in increasing cir-
culation. Passive movements should be limited to moving
the joint once through its greatest range unchecked by
pain and protective spasm. If it is necessary a little
later the joint may be moved once through its entire
range under anesthesia to break adhesions.
Arthritis. Traumatic lesions of the joints are de-
scribed under sprains and dislocations and we are here
concerned with infective and toxic arthritis.
140 ORTHOPEDICS
Toxic Arthritis. The common diseases which often
manifest themselves in joint inflammations are acute
articular rheumatism, tuberculosis, gonorrhea and syphi-
lis. Inflammations of joint tissues, due to the absorption
of toxins from more or less distant foci, are from pyor-
rhea or abscesses around the teeth, infected tonsils, faulty
digestion or insufficient intestinal or kidney elimination.
Acute rheumatic arthritis or rheumatic fever in the
acute and severe stage cannot be treated by orthopedic
measures other than support, but in the mild or chronic
stage can be dealt with in the same manner as arthritis
in general.
Tuberculous arthritis is treated first constitutionally
following the approved methods employed for arresting
any tuberculous process in the body rest, outdoor living
and forced feeding. Locally, by means of brace, exten-
sion or rest in bed, we attempt to immobilize a joint and
remove all weight bearing from it.
Arthritis Deformans, Osteoarthritis, Rheumatoid
Arthritis, Rheumatic Gout. Degenerative and Prolifera^
tive Arthritis. Whitman * of New York, in his treatise
on orthopedic surgery, has given us perhaps the best brief
description of this group of conditions. He says, ** Under
these titles are included a group of chronic diseases of
the joints whose etiology is obscure. At the present
time, as these diseases are often classed as varying
manifestations of one pathological process, the titles are
usually considered as synonymous."
This group of chronic affections of the joints are of
'Orthopedic Surgery." Eoyal Whitman (Lea & Febiger, Philadelphia).
m
JOINT INJURIES AND ARTHRITIS 141
uncertain origin, derangements of the nervous system
probably accounting for a considerable portion of them
and, when present, are associated with marked deteriora-
tion of the skin appendages, the hair, nails, etc.
Clinically, we have two rather sharply defined types,
hypertrophic and atrophic arthritis.
Hypertrophic arthritis occurs from early adult life
through old age. It is often confined to one or more
large joints but associated enlargement of the joints
of the fingers is common. The synovial membranes,
cartilages and periarticular structures are all involved.
According to Da Costa, the changes begin in the cartilage
with a multiplication of the cells and a degeneration of
intercellular substance. Wearing away of the joint*
cartilage in places brings pressure on the bones which
causes thinning, bulging and lengthening by deposits.
The deformity is marked and the motion limited but
without ankylosis. The fingers often show Heberden's
nodes. The process when located in the spine produces
spondylitis deformans.
Atrophic chronic arthritis is largely a disease of child-
hood and early adult life. Its onset is rather more rapid
than the hypertrophic type and more general in its dis-
tribution. The joints become spindle shaped; there is
general muscular atrophy. It is progressive in charac-
ter and the pronounced destruction of cartilage leads to
ankylosis.
Treatment. In no type of arthritis is the constitu-
tional treatment of as great importance as in this condi-
tion. Change of climate, particularly to one both warm
142 ORTHOPEDICS
and dry, is beneficial. Suitable exercise, fresh air, rest
and diet must be provided for. Tonics have their plac
but sedative drugs must be carefully guarded against be-
cause of the long duration of these joint affections. Use,
within the limit of strain, is to be recommended and
strain may be guarded against by a brace if desired. Com-
plete immobilization is only desirable for very short pe-
riods during acute exacerbation, and prolonged fixation
will but lead to earlier ankylosis. Local treatment by
means of the various forms of baking, massage and pas-
sive movements are of value in arresting the progress of
this condition. Operative interference, except for the
removal of solid bodies, or to excise small joints is contra-
indicated.
Acute Rheumatic Arthritis, Rheumatic Fever or Acute
Rheumatism is caused by a micro-organism and is char-
acterized by high fever, multiple joint inflammation and
predisposition to further attacks. It is often compli-
cated by endocarditis. The administration of salicylates,
the application of oil of wintergreen, or lead and opium
wash and the fixation of the affected joints constitute
the treatment.
Acute arthritis secondary to meningitis, scarlet fever,
etc., would receive the same local treatment while the dis-
ease itself was being properly attended to.
Tuberculous Arthritis. The process starts first in a
single joint. Others may later be involved.
Causes. The indirect causes are the lowering of local
resistance of joint structures as a result of trauma,
chilling, or chronic strain. The direct cause is the inva-
JOINT INJURIES AND ARTHRITIS 143
eion of the tissues by the tnbercle bacillus which as a
rule first involves the bone.
Pathology. It spreads from the primary focus by
sinus formation to the synovial membrane and then to
the other parts of the joint. Tubercles form throughout
the joint structures which soften and thicken through
caseation. There is not marked fluid formation. This
process may develop into sinus formation opening ex-
ternally with consequent danger of pyogenic infection.
Symptoms. Swelling is usually not marked. Protec-
tive spasms of the muscles followed by their atrophy is
usually seen. Pain is often referred to structures at
some distance from the involved joint, for instance, in
hip cases to the inner side of the knee, and in spinal
cases to the front of the abdomen. Finally the tissues
become matted together, the joint distinctly rigid, the
skin white and thickened, the whole swelling spindle
shaped. Pain on movement is a constant symptom.
There is danger of systemic involvement with the tuber-
culous process^
Treatment. Constitutional treatment is the same as
for other forms of tuberculosis. Local treatment con-
sists of fixation and extension. Superheated dry air and
Bier's hyperemia are helpful. The joint may be aspirated
and injected with iodoform and glycerin when there is a
large accumulation of fluid. When sinuses are formed,
opening externally, care must be taken to avoid mixed
infection. They may be injected with Beck's bismuth
paste. These conservative measures may prove suffi-
cient. If a trial of such treatment fails to improve the
144 OETHOPEDICS
patient, operation is indicated and should be radical
and thorough. In cases showing amyloid degeneration
attempts at removing sequestra or forming bony anky-
losis of fresh healthy bone are useless and amputation
should be resorted to.
Gonorrheal Arthritis. Gonorrheal arthritis is a com-
plication occurring in about two per cent of the cases of
this disease. Its distribution in order of frequency is
knee, ankle, wrist, shoulder.
Treatment. This is first aimed at clearing up every
focus of infection, particularly the prostate and Bartho-
lin's glands, and unless this is thoroughly done local
treatment is of little avail. A large amount of destruc-
tion may follow the involvement of a joint and lead to
complete bony ankylosis. In the acute stage immobilize
and counter irritate by heat or ichthyol ointment. If
very severe aspirate, irrigate with hot saline and, if joint
fluid is purulent, incise, irrigate and fixate with drainage.
In the subacute stage treat with baking or passive hy-
peremia, massage and gentle passive movements.
Syphilitic Arthritis. Syphilis of the joints is rare as
compared to tuberculosis, the diaphysis of the bone be-
ing the part most often attacked. Hereditary syphilis
manifests itself during infancy as an osteochondritis
which may resemble rickets. It is not, however, usually
bilateral in distribution nor does it usually involve more
than two or three joints at once. In older children an
accompanying periostitis is common and the synovial
membrane may be so thickened as to interfere with nor-
mal joint movement. In acquired syphilis the joint may
JOINT INJURIES AND ARTHRITIS 145
be involved in the secondary and tertiary stages. The
local symptoms are thickening of the joint structures and
increase in its fluid with but slight atrophy of surround-
ing muscles. There is pain on movement but it is not
usually limited by muscle spasm and it often persists
at night. Knee, shoulder and elbow are most often in-
volved. The diagnosis can be confirmed by the other con-
stitutional manifestations of the disease and by the
Wassermann test.
Treatment. Local treatment consists in rest and pro-
tection of the joint. The constitutional treatment is that
usually followed in this disease.
Chapter X
DISEASES OF BONES
Periostitis. Inflammation of the periosteum may be
acute or chronic. Acute periostitis usually foUows in-
jury. There is a local inflammatory process, the pain
from which is marked at night. Function is interfered
with. The swelhng is usually spindle shaped and may
be due to a thickening of the periosteum and the ac-
cumulation of fluid in or beneath it. A subperiosteal
hematoma may form. This is sometimes difficult to dif-
ferentiate from an abscess. The latter would, however,
give much more marked signs of inflammation, together
with constitutional symptoms. The breaking down of
a hematoma through infection may occur and should be
guarded against. Periostitis, secondary to typhoid,
syphilis, tuberculosis and other diseases, is common, but
more apt to be chronic in type and to occur late in the
disease. In syphilis and tuberculosis a slight and un-
noticed injury may lead to localized periostitis.
Pathologically the periosteum becomes thickened, cell
proliferation increases and there is an extravasation of
serum in the tissues. In acute cases a discharging sinus
may form or the bone may become soft through sclerotic
condition of the overlying parts. In chronic cases,
though healing without the formation of a sinus, the
146
DISEASES OF BONES 149
calcareous deposit within the periosteum of the affected
region may cause a roughened, granular character of the
surface.
Treatment. The most important consideration is ab-
solute rest of the diseased part. Complete immobiliza-
tion and elevation should be secured. Swelling and ten-
sion may be relieved by incisions to the bone into which
several small holes may be bored. In acute cases, where
septic conditions exist, the splitting of the periosteum is
advocated. Baking to improve circulation, and massage
to break up granules, and remove excessive exudate are
of utmost value.
Osteitis. This condition, being usually secondary to
periostitis or myelitis, has much the same symptoms.
The manifestation, especially in tuberculous cases, is very
slow, but pain and tenderness are more marked than in
periostitis. Tucerculous osteitis has been referred to
under arthritis. Sequestra, if formed in the bone, should
be excised and all operative procedures, if indicated,
should be radical and thorough.
Osteomyelitis. This acute disease first starts in the
spongy ends or medullary cavity of the bone and may
from there spread into the joint or along the shaft. Its
onset is characterized by high temperature and the gen-
eral symptoms of an acute infection. Suppuration may
take place and an abscess form. Periostitis, which is
usually present, may blur the picture. When this disease
occurs in the vertebrae, the bodies may be broken down
with subsequent injuries to the cord. The infective agent
may be ordinary pyogenic bacteria, tuberculous bacillus,
150 ORTHOPEDICS
the causative agent of typhoid, syphilis, measles, etc., or
by the action of phosphorus in the body. Bone necrosis
may follow rapidly. The concurrent formation of new
bone by the periosteum may develop an irregular cortex
while the deeper layers of the bone are being destroyed.
Direct infection from infected wounds, especially where
the bone is shattered and the circulation impaired, is
common. The process has been likened to gangrene of
the soft parts. A definite line of demarkation between
the sequestrum and true bone is often seen. The dead
bone, if small, is sometimes absorbed. If not, it breaks
down and produces a sinus. Osteomyelitis is extremely
serious, a fatal outcome being not unusual. Its early
diagnosis is most important. The X-ray is an invaluable
aid in the diagnosis in the following up of the condi-
tion.
Treatment. The infected area should be opened freely
and drained. The Carrel-Dakin drip is extremely help-
ful. Autogenous vaccines are sometimes of great as-
sistance. Thyroid medication is also used. In case of a
large amount of bone destruction all the diseased part
may be removed and a bone transplant may prove of
great assistance.
Osteomalacia. Pain and muscular weakness, similar
to conditions in rheumatism or some diseases of the
spinal cord, are the first symptoms of this disease, which
is most frequently found in nursing women, though it may
occur in men and even in children. Increasing deformi-
ties, chiefly in the spinal column and the pelvis, shown
by decrease in height and a waddling gait, are due to the
DISEASES OF BONES 151
progressive softening of the bone, which can seldom be
arrested. Slight injuries often cause fracture, and death
occurs from exhaustion or disease of the lungs.
This condition may be differentiated from rheumatism
by the fact that the pain is found in numerous plaices.
Urinalysis usually discloses the presence of calcium salts
in excess.
As the lime salts are removed the basement substance
remains, retaining its laminated appearance, but further
progression may lead to disintegration and absorption
of this remaining substance.
Treatment. Improved hygiene, tonics, phosphorus
and iodides are useful. When the onset of the disease
is associated with pregnancy, oophorectomy is indicated
and further pregnancy should be avoided. In other types
Sajous recommends epinephrin injection.
Tuberculosis. Tuberculous disease of the bones is
very largely confined to cancellous bone. In the long
bones it would then make its appearance in fairly close
proximity to the joint and from there extend to the
periarticular tissues and often directly into the joint.
Symptoms and treatment of tuberculosis in these lo-
calities have been described under tuberculous arthritis.
Spinal Tuberculosis. The special manifestations of
this disease in the vertebrae have been described under
diseases and abnormalities of the spine.
Chaptee XI
FRACTURES AND DISLOCATIONS
THE UPPER EXTREMITY
Clavicle. Stemo-clavicidar Joint Dislocation. This
joint is dependent almost entirely on its ligaments for
support. Its dislocations are forward, backward and up-
ward, in order of frequency.
In forward dislocations, the sternal end of the clavicle
is prominent and occasionally overlaps part of the
sternum so that the downward inclination of the clavicle
is increased.
In backward dislocation, the prominence is less, and
there may be congestion of the face and neck on the af-
fected side. It is easily reduced by using the arm as
a lever with counter pressure in the axilla, assisted by
deep respiration on the part of the patient. Retention
is obtained by a molded pad and pressure with adhesive
plaster, assisted if necessary by a posterior figure of
eight to hold the shoulder back. The arm is supported
in a sling.
Fractures. Fractures of the clavicle are exceedingly
common. Its exposed position and the fact that it unites
the movable upper extremity and the trunk are the rea-
sons for its frequent fractures. At its inner aspect, the
attached fibers of the sterno-mastoid muscle pull upward
152
FRACTURES AND DISLOCATIONS 153
and the pectoralis major downward, but the direct pull
of the former is nearly at right angles to the bone, that
of the latter more nearly parallel to it. The pull of the
stemo-mastoid is, therefore, stronger and the inner frag-
ment is usually displaced upward. On the outer third
of the bone, the antagonistic pull of the deltoid and the
trapezius are nearly equal and displacement is not usually
marked.
Symptoms. Pain, loss of function, and change of nor-
mal outline immediately follow.
Treatment. Reduce by traction on the shoulder, out-
ward, backward and upward and retain by a permanent
dressing. The modified Velpeau bandage or Sayre*s
dressing is good. In children, the Taylor brace and the
brace devised by Crane of Waterbury are both useful. All
of these dressings need constant care and adjustment
to take up slack and keep the part secure.
Acromio-clavicular Joint Dislocation. The joint is
covered by the superior and inferior clavicular and the
coraco-clavicular ligaments, the deltoid muscle in front
and the trapezius behind adding their support. Dislo-
cation of the clavicle upward is the common injury.
Symptoms. Pain in the joint, moderate loss of func-
tion, prominence of the outer end of the clavicle, and
sometimes prominence of the tip of the scapula are evi-
dent. Sir Robert Jones uses a simple sling for the wrist
and then binds down a small pad on the tip of the clavicle
by a bandage passed under the elbow and knotted firmly
on the shoulder.
Scapula. Fractures. The heavy, springy bed of mus-
154 ORTHOPEDICS
cle nearly surrounding the scapula makes it extreinely
difficult to fracture this bone. The spine and acromion
process, being more exposed, are occasionally fractured.
Separation of the acromial epiphysis, which unites quite
late, may be mistaken for fracture. The fracture may in-
volve the coracoid process, the glenoid cavity, or the
body below the spine.
Symptoms. Loss of function, pain increased by deep
respiration and crepitus are noted. X-ray is often neces-
sary to ascertain the extent, since crepitus may be lack-
ing. In the treatment, prevent muscular pull or move-
ment of the fragment and, if the body is affected, im-
mobilize the scapula as a whole by strapping, Velpeau
bandage or cast. Maintain from four to six weeks. Com-
plete return of function is the rule.
Shoulder. Surgical Anatomy. The shallow socket,
large variety of movement, and exposed position of the
shoulder joint make it the most frequent seat of dislo-
cation. The coracoid and acromion processes of the
scapula and their ligaments, while not entering into the
joint proper, protect it from above and prevent upward
dislocation, making this type the rarest of all. Mobility
being of prime importance, the socket is very shallow and
stability is dependent largely upon the muscles and ten-
dons. The capsular ligament entirely encircles the joint
from the rim of the glenoid cavity to the anatomical neck
of the humerus. It is quite lax and is put upon a tension
only at the limit of arm movement in the various direc-
tions. Muscle tone alone keeps the joint surfaces in ap-
position and the deltoid is mainly responsible for this.
Fk;. o'.t. ('.vnoT I'o.stkuioh Lki; Sim. int.
[X-Ray (Fig. 38) shows injury to external condyle.
Fig. 40. Airplane Splint with Elbow Joint.
FRACTURES AND DISLOCATIONS 157
The brachial plexus and vessels lie just internal to the
head. In injury the capsular ligament is always torn
and more or less harm is often done to the tendons over-
lying it.
Dislocations. In spite of the variety of directions
which the head may take, the following classification is
suflScient :
- -c J f Subcoracoid. (Most common.)
1. Forward. o i, i i
[ Subclavicular.
2. Do^-nward. I Subglenoid. (Very common.)
[ Subglenoid erecta.
o -D V. J { Subacromial. (Fairly common.)
I Subspinous.
4. Upward. (Uncommon.)
Subcoracoid. The head lies just below the coracoid
process, tearing the anterior and inferior part of the
capsule. The humerus is rotated inward ; the subscapu-
laris tendon is sometimes torn. Extreme degrees become
subclavicular.
Subclavicular. In this type the head is further in-
ward and slightly higher and all the structures are more
lacerated. Kocher's method of reduction is inefficient.
We get a flattening and sharpening of the shoulder; the
anterior axillary fold is lower; the elbow is abducted
and the head of the humerus lies beneath the coracoid
process. It is hard to place the hand on the uninjured
shoulder as the arm cannot be abducted. The patient
leans toward the injured side and usually allows the arm
to hang when he is standing.
158 ORTHOPEDICS
Treatment. Subcoracoid dislocation is most" easily
reduced by Kocher's method, the three main manipula-
tions of which are: 1. The surgeon standing in front,
grasps the patient's elbow with his opposite hand and
holds it against the side, grasping the wrist with his
other hand. The elbow is flexed to a right angle and the
arm rotated externally. 2. The elbow is brought gently
inward across the chest, the hand remaining fixed. Slight
force may be used several times if necessary and the head
slips into the glenoid cavity with a distinct sound. The
third manipulation should not be attempted until this
has happened, as replacement usually occurs at this point.
3. This consists in rotating the arm inward, bringing the
hand toward the opposite shoulder.
Another method is by horizontal abduction and manipu-
lation with surgeon's knee or flexed thigh under the axilla
while an assistant exerts traction on the arm. It is of
further advantage to have the scapula fixed. Slight
swinging or rotating of the arm will aid reduction.
Subglenoid. The head escapes through the inferior
and posterior fibers of the capsule, resting below the
acromion process or, in the subspinous variety, further
back under the spine of the scapula.
The shoulder is flattened ; the head cannot be palpated
in its normal position, but below the acromion process;
the humerus is rotated inward and is held in adduction.
Treatment by Kocher's method may be successfully
employed, but in the first movement the elbow should
be farther back to approximately the mid-axillary line.
Reduction may be obtained by traction accompanied by
FRACTURES AND DISLOCATIONS 161
slight rotation and adduction. Operative treatment
should never be necessary in uncomplicated cases.
After treatment. Immobilize for several days to facili-
tate repair and carry arm in sling, but forbid abduction.
Allow slight active movements during the second and
third weeks and obtain complete abduction by the exer-
cises described for this desired result, the patient lying
prone. Common complications are fracture of the sur-
gical neck; associated dislocation is rare. It should
be treated by the open method and the use of McBurney's
hook to replace the head. Fracture of the anatomical
neck is still more rare. Here the head should be wired,
or, if it cannot be replaced, excised. Fracture of the
greater or lesser tuberosity should be wired unless it is
possible, after setting the dislocation, to abduct and ex-
ternally rotate the arm without redislocation. Bone
pegs and screws are sometimes used.
Fracture of the neck of the scapula leaves a movable
joint. The arm is easily adducted; the whole shoulder
dropped. The elbow is raised and retained by a fixating
bandage.
Recurring dislocations are treated by operation with
repair of the rent and occasionally tucks taken in the
relaxed capsular ligament.
Fractures op the Humerus. Fracture of the
Anatomical Neck. The line of fracture seldom follows
the anatomical neck exactly ; often the greater tuberosity
is included. Impaction and the separation of fragments
are common, especially in the aged. There are pain, swell-
162 ORTHOPEDICS
ing and hemorrhage, but the head is in place ; crepitus is
not easily obtained ; the shortening is not great.
When firmly impacted do not attempt to disengage.
Bind the arm with a modified Velpeau bandage, using a
triangular axillary pad. Massage is begun early, passive
movements late ; three weeks at least should elapse. Ab-
duction is then obtained in the prone lying position or
with overhead pulley weights. Several of our patients
have done extremely well when put up in a plaster in
extreme extension for five weeks, followed by massage
and passive movements.
Fractures of the Surgical NecTc. A great tendency to
displacement is manifest in these fractures. The lower
fragment is usually drawn toward the body, rotated in-
ternally and often elevated by the action of the deltoid
and biceps. This is best treated by traction made on the
arm in the line of its long axis with abduction and out-
ward rotation. The abduction should be carried to an
oblique side-upward plane. In this position traction
corrects the overriding and accurate setting is possible.
When secured the arm may then be lowered gently and
with great care, the elbow flexed to less than a right
angle and the arm fixed in this position. When displace-
ment tends to reoccur the arm should again be abducted
as described and fixed in that position in a cast. The fore-
arm should be included to insure external rotation and
may rest easily behind the head.
The unavoidable formation of adhesions after any of
these injuries, should be treated as described in arthritis
of the shoulder as soon as repair is complete.
FRACTURES AND DISLOCATIONS 165
Ankylosis of the Shoulder. Where this complication
is inevitable Jones gives the following directions for ob-
taining the most useful position for the shoulder joint.
He says : ' * First, the arm should be abducted about sixty
degrees or more from the side, movement of the scapula
will easily replace the amount of abduction. Second,
the arm should be rotated out far enough for the hand
to be brought to the back of the head when the shoulder
is raised. Third, the elbow should be a little in front
of the mid-axillary hue, for convenience in handling table
implements, etc.
*'If these three points are attended to during the treat-
ment of an injury of the shoulder in which ankylosis is
inevitable, the muscles about the scapula will soon learn
to increase their range of movement. To hasten this the
patient should assiduously practice all possible move-
ments of the arm.
**A patient with an arm ankylosed in this position can
perform all ordinary movements so unobtrusively that
many people will fail to observe he has any limitation
of movement at the shoulder. * '
Fractures of the Shaft of the Humerus. The wide
range of movement obtained by this bone makes it sub-
ject to a great variety of types of trauma. Single, trans-
verse or oblique through and through fractures are the
usual types. The close apposition of the musculospiral
nerve makes it especially prone to direct injury or to
later compression by the formation of a callus.
These fractures are usually easily recognized by the
deformity, shortening, hemorrhage, point of abnormal
166 ORTHOPEDICS
mobility and crepitus. Treatment will vary according
to the degree and amount of displacement. Simple trac-
tion and manipulation will usually realign the fragments
though anesthesia may be necessary. Fractures are
put up in the same manner as those of the upper end with
the triangular pad in the axilla, splint or plaster sup-
port and bandage to include the body. A protecting cap
of plaster over the shoulder or entire arm, including the
elbow, is of great service.
In the operative treatment, the fixation, which is occa-
sionally necessary, may be secured by bone pegs, screws,
wire or the Lane plate.
Fractures of the Lower End of the Humerus. Surgi-
cal Anatomy. Preston, in his description of the surgical
anatomy, says: "The lower end of the humerus articu-
lates with two bones ; the types of these articulations are
entirely different and the fractures occurring in this re-
gion are complex. The lower end of the bone curves
forward and is flattened from before backward. The
articular surfaces may be described roughly as a cylinder
mounted on the lower end of the shaft, with the axis of the
cylinder nearly transverse to the long axis of the shaft.
The outer end of the cylinder is at a slightly higher level
than the inner end. When the elbow is fully extended the
arm and forearm are not in the same straight line, but
form an angle of about 170 degrees, half of which is
caused by the obliquity of the articular surfaces of the
lower end of the humerus, while the other half is the
result of the position of the bones of the forearm. In
complete extension, therefore, we have the "carrying
FRACTURES AND DISLOCATIONS 167
angle'* while in complete flexion the forearm comes in
contact with and folds directly upon the arm. When
the fragments, in fractures of the lower end of the
humerus, are allowed to unite in deformity, there may be
a disturbance in the carrying angle which is apparent
when the arm is extended, and in addition there may
also be a deformity in which the forearm does not fold
directly against the arm in acute flexion. The carrying
angle varies considerably in different individuals and the
examination should therefore include comparison with
the uninjured elbow. ' ' *
Types of these fractures are commonly transverse
above the condyles or through them. Either of the
condyles may be fractured ; that of the external often in-
cluding the capitellum and the internal, the trochlea.
Fractures of the capitellum by indirect violence, separa-
tion of the epiphysis, Y or T shaped fractures into the
joint are commonly noted fractures with extensive in-
volvement of the lower end of the humerus.
All of these fractures, except those of the olecranon,
are put up with the elbow in extreme flexion. Olecranon
fractures require extension.
Impairment of function is almost certain to follow
incomplete reduction or large callus formation.
Supra-condylar Fractures. When by direct or indi-
rect violence the lower fragment is displaced backward,
reduce by flexion and downward traction on the fore-
arm. Put up fully flexed to prevent callus formation.
Preston, "Fractures and Dislocations," Mosby Company, St. Louis.
Page 120.
168 ORTHOPEDICS
Reduce the extent of the flexion slightly after a few days,
reaching the right angle in about ten days. Passive and
active movements used early should be confined to the
range of movement between semi- and full flexion.
Epicondylar Fractures. Fractures of the epicondyle
not involving the joint or the capitellum are rare. There
is swelling and tenderness of the external condyle. The
fragment is not usually much displaced.
Epitrochlear Fractures. In this type there is separa-
tion of the internal epicondyle not involving the joint
or the trochlea. The symptoms are tenderness, pain and
hemorrhage along the inner side of the arm. Flexion
and extension of the elbow are not usually painful ex-
cept at their extreme limits.
Feactuees Involving the Joint. Fracture of the Ex-
ternnl Condyle. This includes the capitellum, is quite
common and the symptoms resemble epicondylar frac-
ture but are much more severe. There are almost total
loss of function, severe pain and marked swelling. The
joint is very unstable from side to side and may be moved
freely in this direction ; crepitus is usually present. The
deformity is described as * ' gunstock. ' * The fragment is
displaced downward and greatly turned.
Fractures of the Internal Condyle. The break ex-
tends through the trochlea. The same symptoms of pain,
swelling, hemorrhage and crepitus are present on the
inner side; the same lateral mobility is found.
Y shaped or comminuted fractures may partake large-
ly of either or both of the sets of symptoms just described
and are produced by the force of a blow transmitted
FRACTURES AND DISLOCATIONS 169
through the olecranon and splitting the humerus. There
may be backward displacement of the elbow, but the
olecranon is uninjured.
Treatment. The surgeon grasps the back of the el-
bow with one hand, the wrist with the other and exerts
traction on the wrist until the forearm returns to its
normal alignment. The elbow is then fully flexed. Some
force may be required, as it may necessitate pushing back
fragments which have been displaced forward. The
hand behind the elbow can aid this replacement. Com-
plete flexion is absolutely essential.
After Treatment. Jones gives a simple rule for the
protection of any injury about the elbow from too early
movement. It is that the absence of tenderness about
the elbow indicates that it is ready for the second test,
which is the lengthening of the sling and allowing the
wrist to drop three inches. After two days, if the pa-
tient is able actively to flex the elbow fully, he may re-
peat the exercise to full extension daily. If, on the other
hand, the elbow becomes stiff by protective spasm, it is
an index that this procedure is premature and the elbow
should be put up in full flexion for another week. He ad-
vises against the use of the right angle internal splint for
the elbow.
Fractures of the Olecranon. Fracture may be of the
tip only or a large part of the process. If there is no
displacement of the fragment upward a pad placed above
and an anterior splint with the arm fully extended should
secure firm union in two or three weeks.
Fractures involving marked displacemnt by the ao-
170 OETHOPEDICS
tion of the triceps should be fixed by wire, peg or kan-
garoo tendon and then treated as indicated. Care must
be taken not to injure the epiphysis in children and it is
sometimes wiser even with displacement to use the for-
mer method. In cases of elderly persons sufficient func-
tion can usually be obtained by extension and the pad.
Dislocation of the Elbow. Dislocations may be back-
ward, which are very common; outward, which are also
common; inward and forward, which are rare.
Surgical Anatomy. The radio-humeral joint is of the
condyloid variety, while the ulnar-humeral is a hinge
joint. The internal lateral ligament is divided into a
strong anterior and posterior band, as is also the ex-
ternal lateral ligament. Overextension of the elbow is
prevented by the anterior segments of the lateral liga-
ments, the anterior fibers of the capsular ligament and
the checking of the tip of the olecranon at the olecranon
fossa. Overflexion is prevented by resistance of the
lower part of the biceps to the forearm and by the
coronoid process checked by the coronoid fossa.
Backward Dislocations. The forearm is held almost
in extension; the tip of the olecranon is above its usual
plane and more prominent ; the forearm is shortened ; the
triceps tendon is prominent. The coronoid process is
behind the trochlea, the whole forearm rotated slightly
inward, the head of the radius behind the capitellum.
The same pain, immobility and swelling which occur in
other dislocations are of course present. We treat by
hyperextension and traction enough to clear the coronoid
Fig. 45. Extensive Shrapnel Wouxd of Right Arm with Compound Com-
minuted Fracture of Humerus.
Some union with beginning necrosis of loose fragment metallic body 4x6 mm.
in front of injury.
Fig. 46. Machine-gun Bullet Through Condyles of the Left Humerus.
Treated by removable cast February 6, 1919. Elbow nearly ankylosed
only five degrees of movement in flexion. Four weeks of treatment increased
this range to forty degrees.
Fig. 47. Old Infected Gunshot Wound of Upper End of Right Radius and
Ulna Involving Elbow Joint.
Elbow ankylosed.
FRACTURES AND DISLOCATIONS 173
process, and then fixation in complete flexion for two to
three weeks is necessary.
Lateral Dislocations. These dislocations are rare and
can usually be reduced by flexion of the forearm and ex-
tension of the arm, but an anesthetic may be necessary
to thoroughly relax the muscles.
Forward Dislocations. This type is very rare except
with olecranon fracture. Reduction is accomplished by
flexing the forearm and exerting traction under anes-
thesia if necessary.
Myositis Ossificans Traumatica. Improvement in
X-ray technique is revealing this as a rather common
sequela of elbow dislocation, especially of the backward
type. Torn tags of periosteum with its osteo-genetio
power probably start the ossification process. No known
means of arresting or curing this condition are available
but its prevention can to some extent be obtained by the
earliest possible reduction and the limitation of trauma
both then and later. Too early passive and active move-
ments should be avoided. The onset and progress of
the condition, if it occurs, is followed by means of the
X-ray. It is well to warn the patient of the possibility
of this complication and against too early vigorous use
of the arm.
Dislocation of the Radial Head. The orbicular liga-
ment is always torn. Press the head of the radius back
into place, flex fully with the forearm completely supinat-
ed, place pad over the radial head and bandage firmly.
Ankylosis of the Elhoiv. Where it is necessary to fix-
ate the elbow joint it should be done at just about forty*
174 PHYSICAL RECONSTRUCTION
five degrees, as the weight of the arm may in time slightly
increase the angle to about fifty or fifty-five degrees.
Wounds of the Elhow Joint. There has been a large
proportion of septic wounds in the present war, many of
them causing a marked amount of destruction of joint
tissue. An extension wire splint, which will allow the
wound to be dressed without disturbing the joint, the
Carrel-Dakin drip and the use of passive movements
when the inflammation has entirely subsided, are achiev-
ing splendid results.
Fractures of the Head of the Radius. The head is
displaced; crepitus may be obtained by pronating and
supinating the hand, the head not rotating with the shaft.
This sign is absent in impacted cases. The biceps may
pull the upper fragment forward. The pressure pad
should be placed over the upper fragment and the arm
should be fised in moderate flexion. In fractures near the
head acute flexion without the pad is better. In com-
minuted fractures of the head operation is indicated.
After treatment, dressing should be tightened as the
swelling decreases and should be kept on from three to
five weeks.
Fractures of the Shaft of the Radius. There may be
a concavity over the point of fracture when the frag-
ments are displaced toward the ulna. Crepitus can usu-
ally be elicited. The greenstick fracture is the rule in
children and a slight bulging or depression may be the
only sign besides the localized pain.
Fracture of the Ulna. Symptoms are similar to the
Figs. 48 & 49. Compouxd Comminuted Fracture, Oblique of Radius and
Transverse of Ulna with Over-riding of Fragments.
Pieces of shrapnel scattered over hand and wrist.
Fig. 50. Loss of Bone in the 2nd and 3rd Metacarpals with New Joint
Formation. (X-Ray Fig. 48.)
Fig. 51. Loss of Portion of 2nd and 3rd Metacarpal.
FRACTURES AND DISLOCATIONS 177
above. This fracture is commonly caused by the back
kick of an automobile engine.
Fracture of Radiios and Ulna. The deformity is more
marked and sharper and there may be overriding. Green-
stick fractures show less angular deformity and the mo-
bility at the point of the" fracture, seen in through and
through breaks, is not present. All injuries to children
which could cause this type of fracture should be X-rayed.
Setting of transverse fractures is usually not difficult
except where there is overriding. This overriding must
be corrected by traction before attempting to reduce the
angle deformity. In trying to reduce angular deformity
pressure should not be made directly on it, but above.
Care must be taken to avoid tearing the soft parts. Anes-
thesia may be required and the open method can then
be pursued if necessary. A broad single splint will suffice
in greenstick. Anterior and posterior splints of curved
wood may be used where both bones are broken. Much
injury has been done by too tight bandaging. The rule
should be to use one broad splint where possible.
The Wrist. Colles' Fractures. Colles' fracture is a
fracture of the radius about three-quarters of an inch
from its lower end. It is usually associated with back-
ward displacement of the lower fragment, giving rise to
the typical ''silver fork" deformity, with occasional ro-
tation of the lower fragment toward the ulna. The close
approximation of important tendons, the function of
which is interfered with in displacement, makes accurate
reduction of great importance.
Reduction. A new and excellent procedure has been
178 ORTHOPEDICS
outlined by Sir Robert Jones. It is as follows : The sur-
geon grasps the patient's forearm with one hand so that
he can exert pressure against the projecting end of the
shaft; with his other hand on the back of the patient's
wrist he presses on the displaced fragment. A slight pull
and twist under pressure reduces the deformity.*
Another method of reduction is to grasp with the
thumbs above and the first fingers below the two frag-
ments. Use traction on the lower fragment to free it. It
may be necessary to increase the deformity at first to un-
lock impaction. Pressure with the thumbs, especially the
one on the lower fragment to correct its rerotation, will
bring the bones into proper apposition.
Where vicious union has taken place the use of the
Thomas wrench or open operation may be necessary.
Sprains of the wrist and associated synovitis are treat-
ed as those elsewhere. Careful X-ray work will reveal
the fact that many supposed sprains are in reality frac-
tures.
Dislocations. Dislocation of the wrist is rare. The
deformity and tenderness are below the wrist joint. The
tenderness is diffuse and the relation between the styloid
process of the radius and the ulna is undisturbed. These
dislocations are put up in overextension and the usual
treatment applied.
The Hand. Fractures. Fractures of the phalanges
and metacarpals may follow direct violence and are com-
mon in bare-hand fighting.
Jones, Col. Sir Eobert, "Injuries to Joints" ^Frowde, London.
Page 110.
Fig. 52. Extension Applied to Fracture of Both Bones of the Forearm.
Fig. 53. Bradford Frame with Extension .\pplied to Leg for Fracture op
Femur with Shortening.
FRACTURES AND DISLOCATIONS 181
Diagnosis and treatment are usually easy. Fixation
of the clenched hand over a roller bandage with adhesive
is a convenient means of splinting the metacarpals. A
straight posterior splint or, if preferred, an anterior one,
the splint being slightly wider than the finger, may be
used for fixation of the phalanges.
The metacarpo-phalangeal joints are condyloid and al-
low adduction, abduction and circumduction, in addition
to flexion and extension. There are two lateral and one
anterior ligament, the extension tendon serving this pur-
pose posteriorly. There is great variation among differ-
ent individuals in the normal range of movement possi-
ble. The thumb and index finger are the most frequently
injured. These joints may be dislocated in any direc-
tion.
Diagnosis is easily apparent by the displacement of the
finger. Occasionally the anterior ligament makes re-
duction difficult. When there is overriding, increase the
deformity until the distal bone can be started over the
head of the proximal. Fixation with early passive move-
ment is indicated.
Dislocation of the carpal-metacarpal joint is usually
confined to the first, which is easily diagnosed and re-
duced. A curved splint extended over the base of the
thumb will retain the corrected position.
Dislocations. Dislocation of the phalangeal joints is
obvious ; the pain and displacement usually marked. Ex-
tension with accurate setting and the fixation is all that
is required. These injuries are common in athletics,
182 ORTHOPEDICS
often following awkward catching of a baseball or bas-
ketball, and tend to recur easily.
Separation and displacement of the epiphysis instead
of dislocation at the joint is common, and perfect re-
alignment with fixation for two weeks is necessary.
Chapter Xn
FRACTURES AND DISLOCATIONS (Con't)
THE LOWEB EXTREMITY
Pelvis. Types of Fracture. The following varieties of
fracture of the pelvis may be seen : 1. Fracture through
the rami of the ischium. 2. Fracture of the acetabulum.
3. Fracture of the tuberosity of the ischium. 4. Frac-
tures of the iliac crest. 5. Fracture of the anterior su-
perior spines.
Fractures of the Rami. These fractures result from
falls or blows on the front of the pelvis, or by crushing
from the side. They may include the pubic bone or be
complicated by fractures near the sacro-iliac joint or
communicating with it. Displacement is not usually
great, though it may be at first followed by partial re-
turn to position. During its excursion it may extensively
injure the soft parts, which must be carefully examined
for injury in all fractures of this type.
Symptoms noted are hemorrhage, pajn and local ten-
derness, aggravated by leg movements, but are limited
to the affected side. Mobility and crepitus are occasion-
ally present. Displacement is uncommon, but if present
replacement manually is not difficult. We treat by sup-
port by a sandbag, strapping or a snug, heavy bandage,
183
184 ORTHOPEDICS
canvas and leather supports are often useful. Good re-
covery of function is the rule.
When complicated by a fracture at the back of the
pelvis, so-called double-vertical fracture, which is usually
caused by tremendous pressure, the treatment is more
complicated. The fragment is usually displaced upward ;
occasionally the front of one side of the pelvis and the
back of the other is broken, usually with less displace-
ment. The main symptoms are asymmetry, mobility,
pain, etc. X-ray diagnosis is essential.
The pain is felt both front and back on bilateral pres-
sure upon the crests of the ilia. Treat by reducing the
upward displacement by Buck's extension apparatus,
using eighteen to twenty-four pounds. If the patient sur-
vives the extensive shock, fair return of function may be
hoped for.
Fracture of the Acetabulum. This fracture is often
complicated with backward dislocation of the hip joint
and may cause recurrence of the subluxation beside add-
ing to the difficulty of replacement.
Fractures extending through the center of the acetabu-
lum are caused by the impact of the femoral head. Un-
less the head penetrates the acetabulum symptoms are
not marked and the condition is seldom diagnosed. Mo-
bility and the bony landmarks remain about the same.
When complicated with penetration there is often ex-
tensive injury to the soft parts and the injury, though
rare, is usually fatal. Usually the great trochanter of
the femur is less prominent; the fascia lata is relaxed;
occasionally there is outward rotation of the hip; hem-
FRACTURES AND DISLOCATIONS (con't) 185
orrhage is apt to be severe. The leg should be abducted
and extended and a block for counter pressure may be
placed between the thighs so that the femoral head is
wedged.
Prognosis is unfavorable for functional recovery.
Fracture of the Iliac Crests. This occurs from blows
or falls on the side. There is little impairment of func-
tion. Displacement is usually inward. Swelling, tender-
ness, crepitus and internal displacement are marked. It
is possible to reduce the fragment occasionally in thin
subjects. Immobilize with adhesive plaster or bandage
with even, very light pressure. Tight bandaging will
force the fragment inward. Early union takes place, but
at least four weeks must be allowed before the fragment
can be safely pulled upon by its attached muscles.
Fractures of the Anterior Superior Spine. This is
rare, but is occasionally caused by direct muscular action
in sprinting or jumping. Every ''pulled" tendon should
be carefully examined. Displacement is not great.
Flex the leg slightly and immobilize.
Dislocation of the Symphysis Pubis. Diagnosis. This
condition, which is most frequently post-obstetric, is char-
acterized by pain on pressure, or by abduction of the
thighs and usually hemorrhage. More marked separation
is very rare but may occur as a result of falls or horse-
back riding. In such cases the symptoms are more marked
and may be accompanied by laceration of the soft in-
ternal parts, by fractures or by dislocation of the sacro-
iliac joints. One should immobilize by a pelvic girdle,
by traction and immobilization in case of vertical dis-
186 ORTHOPEDICS
placement, or wiring in case of separation without too
extensive injury; generally there results a good restora-
tion of function.
Dislocation of the Hip Joint. Hip dislocation is rare
in comparison with fractures of the femur and does not
warrant the space given to this subject in the average
text-book. It is commonest in the adult male. The
simplest classification is into anterior and posterior types,
according to the position of the femoral head in rela-
tion to the acetabulum and the ligaments, especially the
Y ligament of Bigelow.
T[he anterior dislocations are sometimes divided into
pubic, suprapubic, perineal and obturator types, and the
posterior into ischial and dorsal.
Posterior Dislocations, the commonest type, is usually
caused by falls or blows from in back. Inward rotation
makes possible this backward slipping, especially when
accompanied by adduction and partial flexion. The pos-
terior and inferior fibers of the capsule are torn. The
following muscle tendons and sometimes the muscles
themselves are frequently torn: the obturator externus
and intemus, quadratus and pyriformis and sometimes
the gluteus maximus. The other muscles are less often
affected. When this dislocation occurs the leg is held
flexed and adducted; there is often some real and a
large amount of apparent shortening. The leg is also
inverted and the patient may rest on the sound foot. All
these symptoms are aggravated when the head is dislo-
cated posteriorly and inferiorly and the higher its posi-
tion, the less marked they are. The head is absent from
FRACTURES AND DISLOCATIONS (conH) 187
its normal position and is felt posteriorly and is felt to
move on any movement of the femur. The trochanter is
above Nelaton's line and shortening is found by the usual
measurement from the anterior superior spine to the
internal malleolus. A still more accurate measurement
is by means of Bryant's triangle. The patient supine, a
line between the great trochanter and the anterior su-
perior spine, and a perpendicular line from the anterior
superior spine to the table are drawn. The short side of
the triangle will be the horizontal line between the per-
pendicular and the great trochanter, and it is this line
that is shortened.
Treat by Bigelow's method. Patient supine, the leg
is adducted, flexed and internally rotated followed by
forward traction and abduction. This should be done as
one continuous movement if possible.
There is considerable injury to soft parts by Bige-
low's method which, however, is a great improvement
over the older and more forceful maneuvers. Less injury
is apt to be done by the Allis and gravity method.
The Allis Method. Patient supine, the thigh and knee
are flexed to right angles depressing the head with counter
pressure downward on the pelvis by strap, assistant or
surgeon's foot, the surgeon exerts traction upward as if
trying to lift the patient by the lower leg, the femur per-
pendicular. Gently rotate inward and outward several
times, each followed by upward traction if necessary.
Gravity Method. Patient lies prone, pelvis at end of
table, hip and knee flexed at right angles. Support the
ankle and give gentle pressure downward just behind the
188 ORTHOPEDICS
knee. It may take a little time before the muscles relax
and the bone slips into place. If one or both of these
methods fail, then the Bigelow method should be tried.
Anterior Dislocation. This occurs most often in blows
or falls on the abducted leg. Here, too, the head es-
capes low down and then travels forward through the
lower and anterior fibers. The Y ligament is not usually
injured; the ligamentum teres is usually torn; the mus-
cles are rarely injured. The leg is extended, abducted
and rotated outward; the patient can bear considerable
weight on the leg. The head is displaced inward, gen-
erally below the center of Poupart's ligament. The Y
ligament generally lies in close apposition to the neck
and may be used as a fulcrum to restore the head to place.
Allis Method. The patient lies supine, the surgeon
grasps just behind the flexed knee, abducts the slightly
flexed thigh sharply and exerts traction. An assistant
presses against the head while the thigh is adducted.
Rotation Method. This method is attended by dan-
ger of injury to the soft parts and the sciatic nerve and
should, therefore, be very gently performed. It may
be performed in two ways:
1. Inward Rotation. The thigh is partially flexed and
then, with downward traction, is abducted, adducted and
rotated inward so that the head slips into place and the
thigh may be lowered to full extension.
2. Outward Rotation. The thigh is partially flexed and
adducted, the knee lowered and adducted and the thigh
then rotated outward.
Fractures of the Upper End of the Femur. These
FRACTURES AND DISLOCATIONS (con't) 191
fractures are divided roughly into intra-capsular and
extra-capsular types. Displacement varies slightly by
the plane of the fracture and the direction of the muscle
pull. As a general rule in fractures of the neck there is
overriding of the lower fragment upward which is cor-
rected by extension in the abducted position with slight
inward rotation. Fixation of the pelvis as well as the
leg is essential, and fixation of the whole trunk desirable.
This can be done by means of a posterior body frame-
brace by the Thomas posterior splint or by extending the
plaster cast to the axilla. The question of the amount of
impaction is more important to determine than the exact
location of the break. As a rule impaction favors union.
Fractures at the Epiphysis of the Head. Injury at
this point is of fairly common occurrence among school-
boy athletes. It often follows slight trauma, or repeated
slight trauma, the symptoms of which at the time are
mainly those of hip joint strain or sprain. For this rea-
son it is very often not discovered for some time. All the
movements of the limb may be normal except for some
pain and spasm upon abduction and rotation. Increas-
ing lameness after another similar injury may lead to
an X-ray, when the trouble is discovered. Again the
symptoms may resemble a beginning hip tuberculosis
with some limitation of movement in all directions, and
obvious shortening, the great trochanter being above
Nelaton's line. The symptoms also resemble coxa vara
and some authors call this condition traumatic coxa
vera. We must also differentiate this condition from
Perth's disease, or osteochondritis, with its flattening of
192 ORTHOPEDICS
the head and shortening and thickening of the neck.
Especially difficult is it without the help of the X-ray to
differentiate this condition from late rickets.
Treatment consists in abduction and extension under
anesthesia if necessary with fixation for five or six weeks.
Intracapsular Fractures. Fractures of this type
through the neck of the femur occur most often in late life
as a result of falls. Sudden twists of the leg are suffi-
cient to produce it when the bone is much rarefied.
Pain, mobility, crepitus, and shortening to some extent
are present. Treatment should be by the posterior ab-
duction frame or Thomas splint in extension, abduc-
tion, and slight inward rotation, the correction of the
deformity being verified by the X-ray. Fixation may be
obtained by plaster, in which case the cast should run
from the chest to the toes. Special care to prevent a col-
lection of fluid in the posterior lobe of the lung by too
long recumbency, or the development of pressure sores
must be guarded against.
Extracapsular Fractures. These are more apt to oc-
cur in adult life by severe blows or falls on the trochanter.
There is likely to be firm impaction with little loss of
function and I have known of one heavy woman who
walked for weeks with such a fracture.
More marked shortening occurs than in the previous
type unless there is impaction-. Slight eversion of the
leg, apparent broadening of the trochanter, crepitus and
pain are noted.
The treatment is the same as for the intracapsular
FRACTURES AND DISLOCATIONS (con't) 193
type except when there is marked impaction with de-
formity. Here the impaction must first be broken up.
Fractures of the Shaft of the Femur. These fractures
are apt to be oblique with considerable tearing of the soft
parts.
Symptoms. Great swelling and disability, pain, de-
formity, marked mobility at the seat of the fracture, ro-
tation of the leg at this point and crepitus are noted.
Measurements unless accurate are useless. A simple
rule is to lay the patient on a hard, even surface with a
vertical line corresponding exactly to the sagittal plane
and another at right angles directly under the anterior
superior spines.
For transportation, if necessary, a pillow or roll of
blankets should be placed around the extended leg sup-
ported by side and rear splints of wood. When all the
material is at hand for setting, the patient may be
anesthetized. The foot should be included in the perma-
nent dressing and kept at right angles. Extension should
be by means of weights with the leg elevated by a Brad-
ford frame or bed elevated at the foot.
The Caliper Extension. The caliper or ice tong
method of extension, devised by Major F. A. Berley,
has been used with good success in the army. A small
incision just large enough to admit the point of the
caliper is made just over the most prominent part of
the condyles and they are driven about a quarter of an
inch into the bone, a little higher on the inner side. Care
must be taken not to enter the knee joint. The leg is
slung by a Balkan frame with ten to fifteen pounds weight
194 ORTHOPEDICS
exerting traction in the line of the femur. This position
facilitates nursing the patient, and infection incident to
the use of the tongs has now been reduced to two or
three per cent.
Fractures of the Lower End of the Femur. Surgical
Anatomy. Most of the lateral surface of the condyles is
subcutaneous. The popliteal artery lies close to the pos-
terior surface and is often pressed upon by one of the
fragments. The nerve and vein of the same name are fur-
ther from the bone and not as often injured. The most
common fracture is transverse, just above the condyles,
but they may be fractured separately or a T shaped frac-
ture may extend to the joint. The epiphysis may be
separated. A fragment may be displaced in any direc-
tion but the pull of the gastrocnemius will usually dis-
place the fragment backward. When the epiphysis is
separated, on the other hand, it is usually displaced for-
ward. There are pain, swelling, unnatural mobility; tfie
leg may be helplessly rotated outward ; crepitus may be
present. Soft crepitus denotes epiphyseal separation but
overriding and shortening are the rule.
Anesthesia is usually necessary. Early reduction is
essential because of the danger of possible injury to the
popliteal artery. Since there is great danger of injury to
this vessel by the manipulations incident to setting, great
care must be used. Never press in the popliteal space.
Besides the caliper method mentioned, the Cabot pos-
terior wire splint, the Dupuy adjustable splint or the
Hogden splint may be used. The first two are arranged
in a double inclined plane. Operative treatment is indi-
FKACTURES AND DISLOCATIONS (con't) 195
cated whenever good reduction cannot be obtained. The
incision should be along the inner border of the quadri-
ceps extensor. The use of the bone-hooks or forceps may
be necessary. In fractures involving the joints two in-
cisions may be necessary. Open the knee joint only as a
last resort and then only under rigid aseptic precau-
tions. The Lane plate or bone pegs may be used when
the epiphysis is not involved.
After Treatment. Considerable swelling and some
arthritis of the knee joint are to be expected. The use of
ice is an important aid. Between the second and fourth
weeks the knee should be gradually extended, massage
and passive movements begun; after which an ambula-
tory splint may be worn for two weeks.
Fractures of the Patella. It must be remembered that
the patella is really the sesamoid bone enveloped by the
tendon of the quadriceps extensor, and is attached below
to the tubercle of the tibia by the patellar ligament. Its
under surface directly connects with the knee joint.
Fractures are usually transverse, caused by blows on the
flexed knee. Muscular action alone causes a great many
fractures. Many of them, especially of the lower half,
are comminuted.
Symptoms. Pain with difficulty or inability to extend
the leg is constantly present. Crepitus is present if the
fragments are not too widely separated. The swelling
is rapid and extensive; there is usually considerable
hemorrhage, especially at the sides. With improved
technique the operative method is to be preferred. Bony
union seldom follows conservative treatment. In non-
196 ORTHOPEDICS
operative treatment the leg should be well padded and
splinted behind; the leg and thigh fixed firmly and a
figure of eight strapping crossing at the sides pressing
the fragments firmly together should be used.
Operative Treatment. The knee may be opened by
semi-lunar incision, concave above, or by vertical incision.
The fragments should be wired, preferably by mattress
suture after any blood clot in the joint has been removed
and the joint washed out with saline. The patellar lig-
ament should be inspected for tears and any such re-
paired. In comminuted fractures all small fragments
should be removed. In a recent case of extreme fragmen-
tation following a kick by a horse more than half of the
patella was removed with an excellent functional result.
J. T. Rugh of Philadelphia has demonstrated in a num-
ber of cases that a patient can get along perfectly well
with the bone excised. Passive movements and massage
are indicated after the fourth week. If healing is delayed
protection for several months is indicated.
Dislocations of the Patella. These injuries are not
very common ; the internal are more common than the ex-
ternal subluxations. The symptoms of intense pain, loss
of function, and the easily recognized deformity, are
marked.
Spontaneous reduction may take place. The knee
should be completely extended with the thigh flexed:
Slight pressure is usually enough to cause it to slip back
into place. When the patella is rotated, palpation of the
ligament will show the direction. Old unreduced cases
may necessitate operation.
FRACTURES AND DISLOCATIONS (con't) 197
After Treatment. A supporting bandage, and ice-cap
if necessary, are used, and careful use of the knee for
some time should be insisted upon.
Dislocation of the Knee. This is a rare condition. The
most common type is forward and backward, outward and
inward in order. We get pain, swelling, loss of function
and considerable shock.
Treat by traction. Buck's extension if necessary. Oper-
ation may be necessary in complete dislocation. Immob-
ilize for three months with a posterior splint and watch
the circulation carefully. Stimulation and opiates are
sometimes required by the patient's general condition.
Immobilize for three months, using baking frequently.
Fractures amd Dislocations of the Semi-lunar Carti-
lages. These cartilages are semi-lunar in shape, thick-
ened at their margin, the inner edge being free in the
joint. The internal cartilage is closely associated with the
internal lateral ligament and they are both affected by the
same type of strain. Sudden pain in the knee after strain
or injury and partial flexion is noted. The joint locks and
extension is impossible. After manipulation a sudden
snap is felt in the joint with return of normal function.
Inflammatory reaction is set up in the joint tissues and
persists for a varying length of time. Recurrence with
increasing frequency is the rule. Occasionally locking is
not present. The internal cartilage is the most often in-
jured. The pain may be here or referred to the patella.
Place the patient prone, knee flexed, rotate slowly from
side to side. Flexing the knee over the surgeon's wrist is
a means of separating the articular surfaces of the joint.
198 ORTHOPEDICS
Free, painless extension is the sign of reduction of the
deformity. The knee should then be protected from over-
use or strain by a simple hinge brace. In recurrent cases
the cartilage should be excised.
Rupture of the Crucial Ligaments. This follows se-
vere twists of the knee. Almost immediately there are
severe pain and great swelling which make the joint inse-
cure. The function of the anterior ligament is to prevent
forward displacement of the tibia and it is tense in com-
plete extension of the leg. The posterior ligament, on
the other hand, holds the tibia forward and is placed in
tension when the knee is completely flexed. Acting to-
gether, they prevent twisting of the leg inward. Testing
these different movements will show the extent of the in-
jury which has taken place.
Treat by fixation in extension; a posterior splint fol-
lowed by the use of the hinge brace is recommended.
Operative interference is seldom indicated. The spine of
the tibia is sometimes torn off in association with rup-
ture of these ligaments. The knee should be put up in full
extension. X-ray diagnosis is essential.
Fracture of the Upper End of the Tibia and Fibula.
Fractures of Tibial Tuberosities. We find disability,
pain, swelling and traumatic arthritis are present ; lateral
stability of the knee is often lost. The deformity is
usually recognized since it is subcutaneous. Separation
of the upper epiphysis of the tibia is rather rare; the
fragment may be displaced in any direction and crepitus
is soft.
Fracture of the Upper End of the Fibula, There are
FRACTURES AND DISLOCATIONS (con't) 201
pain and local tenderness, but less involvement of the
knee and less disability; the head may be movable; the
perineal nerve may be injured. Reduce, immobilize, and
begin passive movement and massage the third week. In
case of impaction use Buck's extension. Operative treat-
ment may be necessary. Treatment may have to be ap-
plied to the knee joint.
Fractures of the Shaft of the Tibia and Fibula. These
fractures are rather common from either direct or indi-
rect violence. Fracture of either bone separately is
usually the result of a direct blow. Compound fractures
are common.
Pain, swelling and deformity, abnormal mobility, and
crepitus are common. Abnormal mobility is greater when
both bones are broken. There may be little loss of func-
tion in fractures of the fibula alone. Hemorrhage is often
severe. The greenstick fractures of chOdren sometimes
present few symptoms but pain and bowing. The diagno-
sis is made by X-ray.
For transportation the leg should be splinted both sides
and rear, supported below the foot and well padded. Ex-
tension applied to the foot flexed nearly to a right angle is
useful. Posterior wire splints or plaster splints are com-
monly used. Operative treatment should be instituted
wherever good apposition is otherwise impossible. An
ambulatory splint should be used if possible at the end
of the first week. Great caution is necessary when begin-
ning use of the limb. Weight bearing should be extremely
gradual and the condition of the callus watched by the
202 ORTHOPEDICS
X-ray. Heat, massage, and passive movements of the
ankle and knee should be used early.
Fractures of the Lower End of the Tibia and Fibula.
Pott's Fracture, This is a combination of fracture and
dislocation.
Surgical Anatomy. The ankle joint is formed by the
fibula externally, the tibia above and internally and the
astragalus below. The two leg bones are bound by the
strong tibio-fibular ligaments. The lateral Ugaments are
also very strong and are more apt to be pulled away than
torn through. The external malleolus is longer and lower
than the internal. The weight-bearing surface of the
heel is slightly outside in the longitudinal plane of the
tibia, hence, landing squarely on the feet with great force
tends to lateral and upward displacement of the foot.
This force is applied directly against the lower end of the
fibula and on the internal lateral ligament. Either this
ligament is ruptured or the tip of the malleolus is torn off.
There are absolute loss of function, pain, swelling and
characteristic eversion of the foot; the greater promi-
nence of the internal malleolus ; crepitus is usually lack-
ing and the heel may appear prominent. Marked swell-
ing may mask the symptoms; delayed hemorrhage is
often seen.
Inversion and upward replacement of the foot is nec-
essary. The padded internal splint of Dupuytren should
be used early. The padding just above the fracture is
used as a fulcrum to invert the foot. The Cabot wire
splint may be used throughout. Stimson*s plaster splint
is best after the first week. It consists of a posterior seg-
FKACTURES AND DISLOCATIONS (con't) 203
ment from the knee to the toes and an external one which
is continued beneath the foot and over its dorsum to the
external malleolus. The foot must be placed at a right
angle. The splint should remain on five or six weeks,
massage begun in the second week. Weight bearing
should be gradual and guarded.
Fracture of Both Bones Above the Ankle. The symp-
toms are pain, swelling, loss of function, crepitus, preter-
natural mobility. The deformity is usually marked and
easily recognized.
Treatment is the same as for fractures of the shaft.
Dislocation of the Ankle. These are usually forward
or backward. Lateral dislocations are generally associ-
ated with fracture.
Posterior Dislocations. Prominence of the tibia and
the obvious deformity are seen.
Place the patient supine, fix the ankle with traction
downward, grasp behind the heel, pull backward, down-
ward, forward.
Forward Dislocations. This is usually associated with
fracture, and if so, operative treatment may be necessary.
Fractures of the Tarsus. These should be diagnosed
by the X-ray, replaced as well as possible and immobilized
with plaster.
Fractures of the Metatarsus. The symptoms vary
greatly with the severity of the injury. Crushed wounds
often cause multiple fractures with extensive damage to
the soft parts. Pain, swelling, crepitus, and tenderness
are the usual symptoms. Pressure beneath the toes on
the head of the metatarsal bones is one method of elicit-
204 OBTHOPEDICS
ing pain. Eeduce the deformity by pressure pad and
immobilize in a cast.
Fractures and Dislocations of the Phalanges. The
symptoms are similar to those described for the fingers.
The deformity should be reduced and the foot encased in
plaster. Where the injury has been done to the great toe,
the patient should not be allowed to walk until bony union
has taken place or inflammatory reaction has subsided.
In the other phalanges use may be allowed much earlier.
Chapteb XIII
FOOT STRAIN
The Main Arch. Classification. Three degrees of this
condition have been described:
1. The weak foot. This is a condition in which the
patient complains of discomfort or pain in the arch when
overfatigued or following prolonged use of the foot, es-
pecially during hot weather. The arch is little, if any,
lowered.
2. The strained foot. Here the arch is coming down.
The pain is very severe and may be referred to the back
of the leg, front of the thigh, or even the back. The sca-
phoid is usually prominent. This condition must be vis-
ualized as the breaking stage.
3. Absolute flat foot. Here the damage has been done.
The arch is flat and the inner border of the foot bulges
considerably. There is no pain and, indeed, sometimes
never has been, if the condition is gradual enough in its
onset. The patient often consults the orthopedist because
some person has told him he is flat footed, or because he
has been rejected from the service. The author has been
consulted by many young men, from naval recruiting sta-
tions, who were utterly unaware of the existence of this
condition or their probable rejection from the service on.
account of it.
205
206 ORTHOPEDICS
Causes. Before any intelligent conception of the rea-
sons underlying the great prevalence of this condition can
be gained, it is necessary to consider the way in which
savage, or natural, man used his feet, and the extensive
changes that civilization has brought about. The normal
movement of the bare or moccasined foot in walking is a
grasping one, which constantly exercises the three layers
of muscle whose normal tone, with the long and short
plantar ligaments, helps to retain the form of the arch.
The foot is pointed straight forward or slightly toeing in ;
the heel, outer border, ball of the foot and toes carry the
weight.
"We no longer usually walk upon sand or springy turf,
but a rapidly increasing part of our population is con-
demned to solid pavements and hardwood floors, and such
conditions cause strain. It being considered the proper
thing to toe out, it is insisted upon that the child fall in
line with this convention. In such a foot position, since the
momentum of the body is going straight forward, if the
weight hits the heel on the outer side with the foot
everted, it must necessarily be transmitted across the foot
directly onto the arch, instead of along the outer border
of the foot, and straight forward.
We further impede normal use of the arch muscles by
placing a rigid leather sole on the shoe. In women's shoes
several points in consideration of the heel are important.
The very high heel, by causing long held contraction of
the calf muscle, may lead to its structural shortening.
This height induces an artificially high arch, which is
withal a weak one. It makes such a steep incline in the
^K^R^^^^^^^^^^^^^^^^^^^^V
'Hi ^HK^
Fig. 59. Exercise II. Walking Forward on Outer Edge.
Fig. 60. Exercise III. Rising on Toes, Toeing in.
Fig. 61. Exercise IV. Walking Forward on Outer Edge, Toeing in.
Fig. 62. Exercise V. Ground Gripper Walk.
FOOT STRAIN 209
shank that efficient weight bearing there is impossible and
the weight is unduly thrust forward onto the ball of the
foot. Constant variations in the height of the heel are in
themselves a danger because they do not allow time for
readjustment of the muscles and ligaments to varied
planes of weight bearing. Moreover, these heels are
usually extremely small in base, which necessitates a stilt-
like balancing by the muscles of the leg. This is a most
severe type of exertion and, occurring in that part of the
body where the removal of waste products is most slug-
gish, it is no wonder that fatigue and strain almost inev-
itably ensue. Still further, the shortness of such a heel
fails to give support far enough forward under the os
calcis and so brings increased strain on the arch. The
constricted fore part of the shoe, absolutely eliminating
the normal spread and movement of the toes, adds its
quota of injury. Occupations requiring long standing or
the enforced immobility of the muscles of the foot are a
far more frequent cause of flat foot than walking. Cer-
tain constitutional conditions predispose to arch trouble,
especially the general lack of muscular tone following
acute or chronic illness, too rapid growth, or any other
condition which lowers bodily tone.
Diagnosis. Heretofore great emphasis has been placed
upon the arch impression, which, when normal, is sup-
posed to be broad in the heel and ball of the foot and to
show only the outer border between them. A low or
fallen arch is indicated by the breadth of the central part
of this impression, with sometimes a total obliteration of
the curved indentation of the arch in the normal impres-
210 OETHOPEDICS
son. Impressions are commonly taken by means of water,
powder, lamp black, ferric chloride solution, or other sub-
stance applied to the soles, the patient standing with feet
parallel and about six inches apart, his weight evenly dis-
tributed on both feet. The ferric chloride or lamp blacked
paper shellacked may serve for permanent record. An
ingenious device is the small plate glass stand with slant-
ing mirror beneath, showing the pressure imprint of the
arch to the surgeon standing in front. I take it that these
impressions are of little intrinsic value except when kept
in series as a record of the success of the treatment given.
The most painful arches I have ever seen have been nat-
urally high ones that were beginning to break. On the
other hand, the exanodnations of several hundred normal
students of physical education have shown, in a great
majority of cases, the low strong arch with no untoward
symptoms. This fact confirms the conclusions of Major
John Ridlon of Chicago, embodied in his advice to sur-
geons examining for the service, that the low arch, show-
ing good strength of the intrinsic muscles of the foot and
without painful symptoms, was much more apt to stand
up under forced marching than the very high arch. The
pain, with its frequent reference to more or less remote
parts of the body, is important. Abduction of the fore
part of the foot must be looked for in all types. A ridge
of callus along the outer edge of the foot is a sure sign of
faulty weight bearing.
No treatment should be instituted without inverting the
foot and passively flexing it to determine the angle of
dorsal flexion, which should be ten to fifteen degrees less
FOOT STRAIN 211
than a right angle. A flexion limited to a right angle or
more shows the mnscle-bound foot described by Hibbs.
l^roper treatment for that condition, consisting of the
fi' stretching of the calf muscle, if possible, if not, by oper-
ative lengthening of the Achilles tendon, must be insti-
tuted before attempting to treat the arch. These pa-
tients receive a strain or stretching of the calf muscle just
as the heel leaves the ground in the step, and, in order to
decrease the amount of foot flexion necessary, they turn
the foot out more and more. This, as before shown, trans-
mits the weight more directly onto the arch and aggra-
vates the strain upon it. They are given temporary re-
lief by certain plates, but, more often, by a higher heel,
until the calf muscle takes up the new slack, when the
vicious cycle is repeated. In numerous clinics I have seen
patients arrive with a bagful of arches of various de-
scriptions, when this condition, the root of their trouble,
has been overlooked.
Treatment. Individual cause must first be sought and
if possible eliminated. The patient should walk with the
foot straight forward. He should wear a heel of moder-
ate height, broad and long, especially on the inner side.
A wide, sensible heel and a flexible shank is often of ad-
vantage. Beginning cases, as of type 1, may often be
cured by two or three strappings and a program of exer-
cises. The other two types need all the resources at our
command.
Strapping. Strapping is usually done in one of two
ways : 1. The partial figure of 8. This is a long doubled
strapping starting at the inner border of the tibia, cross-
212 ORTHOPEDICS
ing the front of the ankle and the external malleolus, go-
ing under the heel at the anterior border of the os calcis
to the internal malleolus, crossing in front of the ankle
and attached to the outer side of the leg. This strapping
is intended to lift up the front part of the heel and makes
no attempt at holding the foot in inversion. It takes little
plaster, is quickly and easily applied and is a good type
for dispensary work.
2. The basket strapping. This consists of two sets of
six straps each, the shorter set in length from the base of
the toes to about an inch over the heel, the other set six
inches longer. With the foot flexed to a right angle and
inverted the first short strap is placed from the base of
the small toe to the back of the outside of the heel. The
second and long strap is started just over the dorsum of
the foot at the base of the little toe, is carried diagonally
under the ball of the foot, back to the anterior part of the
arch, up across the front of the ankle, to the outer side of
the leg. The third is placed parallel to the first, overlap-
ping it one-half in the direction of the arch. The fourth
is parallel to the second and slightly posterior to it, so
that it overlaps it one-half. The rest are placed in alter-
nation, until the arch is covered and supported in its cen-
ter by four thicknesses, the result of the interweaving of
the two groups. This strapping holds the foot in slight
inversion, supports the arch through its entire length,
and has been most satisfactory in practice. Such a strap-
ping should last from four to seven days and will relieve
symptoms while a plate is being made.
Arch Plates. There are two principles involved in the
FOOT STRAIN 215
prescribing of arch supports. One is thoroughly to sup-
port the arch and relieve the symptoms consequent to
strain, the other partially to support and assist the arch
muscles in regaining their tone. The first principle is
typified by the Whitman plate, which is made from a cast
of the foot and so gives perfect support. It consists of
an outer flange, preventing displacement of the support,
and a high inner flange, which supports the scaphoid and
prevents the rolling in of the ankle. I believe this to be
the best plate for patients beyond middle life, those dis-
tinctly over weight, or those whose feet are rigid. A sec-
ond plate, on the principle of a sling or hammock for the
arch, improved on greatly by E. H. Arnold of New
Haven, gives partial support to the arch by means of two
ribbons placed under the arch, one passing over the dor-
sum of the foot, the other under the heel, buckling in front
of the internal malleolus. This plate allows considerable
movement in the foot muscles without abduction of the
forefoot, and in young and strong patients, where the
ability to regain normal muscular power remains, has
given extremely satisfactory results. The leaving off of
this support, after it has performed its function, does not
usually lead to a renewed relaxation of the arch muscles.
The ordinary stock plate neither fits the individual pa-
tient, nor assists the return of muscular function, nor
gives adequate support and, therefore, is usually a fail-
ure. Moreover, nearly every type of arch plate on the
market compels the abduction of the forefoot.
Massage. Frictions of the arch can be done easily by
the patient himself and should be followed by stroking.
216 ORTHOPEDICS
This is a valuable means of improving the circulation and
relieving fatigue.
Exercises. Of the many kinds of exercise that have
been tried the following are typical examples and, when
coupled with the above outlined forms of treatment, will
greatly hasten a return to normal:
1. Stand with the feet parallel and roll out.
2. Stand with the feet parallel and walk forward on
the outer edge, keeping the toes flexed as far as
possible.
3. Toe in and rise on toes.
4. Walk forward on the outer edge, toeing in.
5. Ground gripper walk. Step forward, flex the toes
. to the greatest possible extent, and relax. Re-
peat step forward with other foot.
6. Pick up marbles with the toes.
Anterior arch. The anterior arch extends transversely
across the fore part of the foot and is formed by the an-
terior ends of the metatarsal bones at right angles to the
main arch. It is supported by the transverse metatarsal
ligament and the transversus pedis muscle. Strictly
speaking, it is not a real arch since it always disappears
under weight bearing.
Cause. Obliteration of the anterior arch, often called
** anterior metatarsalgia,'' is very much more frequently
diagnosed now than a few years ago. Its more common
occurrence is, in large measure, due to the increased
vogue of the thin-soled, high-heeled shoe and pump, and,
to some extent, to the increased amount of hard pave-
FOOT STRAIN 217
ments. With the falling of the main arch there is an in-
ternal rotation at the metatarso-phalangeal joint that pro-
duces marked ligamental strain.
Diagnosis. As before stated, the high heel necessitates
the crowding forward of an undue amount of weight upon
the ball of the foot. The thin sole very frequently curls,
in such a way as to form a hollow inside the shoe. Into
this the anterior arch is apt to fall, by first spreading the
but slightly resistant upper of the shoe, and then drop-
ping and assuming the shape of the sole. Nature may at-
tempt to build it up by forming, underneath the foot, a
pad of callus, which is often the first sign of impending
trouble at this point. The pain is sharply localized near
the head of the second metatarsal bone and is extremely
acute in character. An interesting case in point is that
of a young woman of nineteen, who came to the dispen-
sary with all the classic symptoms of this condition. Her
case had been diagnosed and routine treatment had been
applied on several occasions without result. X-ray
showed tuberculosis of the distal end of the second meta-
tarsal bone of each foot, an extremely rare bilateral man-
ifestation of this disease, which was then treated by the
appropriate means with good result. I cite this case as
an example of the fact that, where the recognized treat-
ment of any apparent orthopedic condition has repeat-
edly failed, we should exhaust all means at our command
before giving the case up or continuing the ineffectual
treatment. It must not be forgotten that one may be
dealing with a referred pain from longitudinal arch
strain.
218 ORTHOPEDICS
Treatment. The treatment of this condition is, first, to
eliminate the cause, for instance, by a thick-soled, sen-
sible shoe ; by the removal of the of ttimes painful callus
by chromic acid or other means ; by the use of strapping,
or a support, as well as passively attempting to remold
the arch ; by the use of exercises, one being a picking up
of marbles or other small objects with the toes. Other
exercises, such as flexion and extension and the longi-
tudinal arch exercises, help greatly. Sometimes a circu-
lar adhesive strapping running several times around the
fore part of the foot, the arch being held in a corrected
position, will suflSce. A very excellent pad can be made
from a circular piece of chamois, a little larger than a
silver dollar, surrounding a piece of cotton and securely
sewed, so as to be about the size of a half dollar and two
or three times as thick. If this is not at hand, a simple
pad of cotton will often bring immediate relief when held
in place by the above mentioned circular adhesive strap-
ping. A laced "collar" with pocket for pad is usefuL
AKMY TREATMENT OP FOOT AILMENTS
Strained Foot. The methods of classifying and treat-
ing acute and chronic foot strain in the Army is so dif-
ferent from that heretofore used in private practice, that
to avoid confusion it may be dealt with separately in this
section.
Literature. The latest material will be found in the
"War Department Manual, "Minor Foot Ailments" and
"Medical Manual No. 4" (Military Orthopaedic Surgery),
Colonel Sir Robert Jones ' work on * ' Military Orthopaed-
FOOT STRAIN 219
ics," Colonel Munson's book, **The Soldier's Foot and
the Military Shoe," and the printed lectures of Captain
W. J. Merrill of Philadelphia, delivered at the Camp
Greenleaf School.
Viewpoint of Military Orthopedics, It is now the con-
sensus of opinion that we are dealing with soldiers dis-
abled or potentially disabled (amounting at times to ten
per cent of the troops) by (1) weak muscles, (2) acute
or chronic foot strain, (3) arthritis or ostitis, secondary
to focal or systematic infection.
Classification. Following to some extent the classifi-
cation of Jones, the soldiers ' feet are divided into the fol-
lowing types: (1) Weak foot, (2) Flaccid flat foot, (3)
Rigid foot: (a) Muscle bound, (b) Contracted, (c) Rigid,
(d) Spastic, (e) Claw (first, second and third degrees).
Anatomy. The weight bearing is done normally when
the heel is raised, by the inner three segments of the meta-
tarsals, cuneiforms, scaphoid and astragalus. The os cal-
cis, cuboid and outer two metatarsals add lateral stability.
Movement involving flexion and extension of the foot
or, as it is called in the Army, plantar flexion and dorsal
flexion takes place on the trochlear surface of the as-
tragalus. Lateral movement occurs in the subastraga-
loid joint and between the head of that bone and the
scaphoid. (This point is important to bear in mind when
judging the claims for merit of several styles of shoes
which are supposed properly to adduct the foot. In the
types I have in mind the foot is not grasped far enough
back by the shoe, and the toes are merely crowded out
of alignment.) It should never be forgotten that liga-
220 ORTHOPEDICS
ments are non-elastic and non-sensitive, and that the
pain of strained foot occurs very often where the liga-
ments attach to or pierce the periosteum, which struc-
ture is extremely sensitive.
Methods of Examination. "The examination of the
soldier's feet begins at his head." This axiom indicates
the close association and importance of bodily posture to
foot strain. A clear picture of the normal posture and
normal foot must constantly be kept in mind. (Place pa-
tient's feet parallel and six inches apart.) Determine the
lines of weight bearing. They should pass anteriorly
through the center of the patella, the crest of the tibia
and the middle of the second toe. In the rear from the
center of the popliteal space to just outside the center of
the heel. Examine carefully for scars, discolorations,
swellings, sweating. Note the condition of the toes
corns, callosities, hallux valgus, etc. Manipulate thor-
oughly to bring out any restriction of normal motion or
roughening of joint surfaces. The following exercises
will be of service in the examination: 1. Dorsal flexion
(overextension) of the toes, kept straight. 2. Eise on
heels, foot dosi-flexed. 3. Rise on toes, avert ankles. 4.
Supinate foot (bear weight on outer edge) and flex toes.
Diagnosis and Treatment. 1. Weak Foot. In this
type we find slight pronation. This foot cannot perform
the common exercise movements normally. The muscles
are untrained and hence liable to break down under un-
usual exertion. Any foot which shows the weakness out
of proportion to the obvious deformity should be placed
in this group. These feet should be treated by proper
FOOT STRAIN 221
shoes with wedge or Thomas heel if desired, exercises,
passive movements, massage and contrast baths. This
type must be noted in the history.
2. Flaccid Flat Foot. There is much obvious deform-
ity in this type marked pronation, prominent scaphoid,
abducted forefoot, and often flattened transverse arch.
The important point is, however, that the foot can go
through the standard exercises in a nearly normal man-
ner. The treatment is similar to that just given for weak
foot.
3. Advanced Type with Joint and Muscle Complica-
tions.
(a) Muscle Bound. These conditions are brought
about by over-use per se, at times but a careful search will
generally reveal some constitutional disorder at the root
of it. Indeed, Captain Merrill states that in his opinion
over ninety-five per cent of these cases are due to infec-
tion somewhere in the body. The teeth, tonsils, gastro-
intestinal tract, urethra or prostate are the points of pre-
dilection.
We must then seek the focus of infection and if still
active, eliminate it. This done, a short rest from strain
will allow of nearly normal movements being executed.
The treatment by massage, exercises, etc., will then rap-
idly restore the foot to full usefulness.
(b) Contracted. Here there is actual structural short-
ening added to muscle spasm. The conditions found in
the muscle-bound foot are present in aggravated form.
Try to locate the constitutional predisposing cause.
Treat as above outlined.
222 ORTHOPEDICS
(c) Rigid. An infectious process has been at work on
the joints of the tarsus and mid-tarsus. Gonorrhea is a
common cause, supplemented by foot strain. Here pros-
tatic massage and medication should be added. If the
palliative measures used above do not cause a return of
flexibility the patient may be anesthetized, the foot placed
over a padded Koenig block and the adhesions broken up.
Pl&ce in a cast, the foot being inverted, flexed to 90 de-
grees and supinated. It should remain in the cast two or
three weeks and then the regular treatment instituted as
for the other types heretofore outlined.
(d) Spastic. In this type we have the added feature
of a marked pronation maintained by the spasm of the
peronei muscles. These tendons must first be lengthened
by tenotomy or better by tenoplasty. The latter is done
by two transverse cuts from opposite sides of the tendon
extending halfway through and then stretching it until it
tears within its sheath, giving the desired and usually
permanent lengthening. Put up in plaster and treat as
above. *
(e) Claw. This condition is always progressive,
usually rapidly so, and is a cause for rejection from the
service. Several varieties are described. First Degree :
(a) First toe contracted, (b) the other toes contracted,
(c) all contracted. Second Degree : An intensification of
the first, with marked varus of the os calcis, callosities
and short tendo Achillis. Third Degree (Jones' Fifth
Degree) : Intense neuro-vascular changes, with blisters,
blebs and gangrene. Sometimes also deep-seated, painful
callosities and corns. Treat by the palliative methods
FOOT STRAIN 223
given with a great deal of dry hot air. The first degree
may be relieved by fasciotomy and tenoplasty. Lift up
the heads of the metatarsal bones by fixing the extensor
tendons to the heads of the phalanges. Occasionally the
flexor tendons are fixed to the proximal heads of the
phalanges. In the second degree operate at once. In the
third degree it may be necessary, because of the poor cir-
culation, to amputate the toes or to perform an astraga-
lectomy.
Acute Foot Strain. This condition occurs most often
in the new recruit, and is treated by rest in the recum-
bent position. The pain, swelling and tenderness rapid-
ly subside when massage, passive movements, active
movements without weight bearing, and finally walking
are resumed as soon as they can be done without pain.
In the more severe types strap with double stirrup-
strapping or partial figure-of-eight already described, or
else place in the corrected position with knee flexed, and
apply a plaster of Paris splint, from the toes to the mid-
dle of the thigh.
Chronic Foot Strain. Here the onset is slower. The
typical symptoms are the pain and stiffness on first get-
ting onto the feet in the morning, which may return
toward night with fatigue of the muscles. Change the
occupation so as to relieve the feet from strain. Order
proper shoes, strapping, or arch if necessary, and treat
as above.
Hammer Toe. Never amputate for this condition ; re-
member that every toe in its normal position contributes
224
ORTHOPEDICS
to the lateral support of the others. If due to habit, it
may be corrected by strapping from base to tip, running
under the adjoining toes and over the hammer toe. Cut
the flexor tendon if necessary.
Corrective Appliances for Shoes. In the Army no re-
movable appliance may be worn by men on active duty.
An intensive study of the methods by which the shoe
itself may be altered by any cobbler has been most suc-
cessful in its results.
(A) Long inner wedge inserted, between the layers of the sole, to help
Bupinate the foot extended under the first four metatarso-phalangeal joints.
(B) The "D" shaped wedge of Jones for the same purpose.
(C) The Thomas Heel. "C" the higher (% to % inch) inner side for
eversion. **Cr" the flare on the inside of the heel to add stability.
(D) Jones across bar now inserted between the layers of the sole for
anterior arch trouble.
(E) Steel insert to prevent weak shank from adding to foot strain on
rough ground.
TREATMENT OF MINOR FOOT AILMENTS
Synovitis of Anterior Tendons. Lace the shoes only
with the broad ribbon laces laid flat. At the fifth holes
carry lacer through twice to retain snugness below, and
prevent the foot going forward in the shoe. Above the
fifth eyelets lace loosely and tie behind so puttees do not
press on knot. Massage (effleurage upward), rest, bake
FOOT STRAIN 225
or paint with iodine, for curative treatment. Watch for
and treat constitutional disorders.
Blisters, (a) Small superficial type, open with sterile
needle at periphery if desired. Place pad on sticky side
of plaster directly over the blister, and strap tightly to
promote absorption, (b) Deeply inflamed type. Clean
hands and area carefully. Open at periphery with sterile
needle or bistoury. Press out all exudate. Paint with
iodine or ambrine, pad and strap tightly. Be careful al-
ways not to break the skin on top of the blister.
Abrasions. Disinfect with iodine or alcohol. Pad
and strap if caused by puttee or knotted laces, readjust
shoe lace as above indicated.
Fissures. Clean out superficial ones with iodine 21/^
per cent, pad and strap. Cauterize deep ones with silver
nitrate, pad and strap.
Over-Riding Toes. These are not important except for
the liability of corn formation, and can be neglected.
Corns. No man in the service is allowed to have his
corns cut or pared. Their deep and irregular under sur-
face makes the liability to infection very great. Eemove
the cause, which is generally pressure by improperly fit-
ting shoes. Clean and dry the corn and apply the stand-
ard corn collodion. Dress with gauze and reapply every
other night for six to ten days ; after a thorough soaking,
the com can then be lifted out in its entirety by some
blunt instrument. Fulguration will usually cure.
Soft Corns. Clean carefully, apply corn salve, cov-
ered by a pledget of wet gauze, bring the toes together
226 ORTHOPEDICS
and strap them; bathing the feet frequently with cold
water and proper shoes will prevent their formation.
Callosities. Soak with water, scrape and apply com
salve. Chromic acid or excision may be necessary for the
removal of deep ones.
Warts. These growths are of great importance, as the
pain from even a very small one may cause foot strain in
the effort to avoid weight bearing on them. They are es-
sentially fungi, have hard glistening surfaces and dark
spots in them. Ring them with vaseline or other grease
and paint with glacial, acetic or nitric acid. Dress and
strap, treating the same number of times as directed for
corns. Fulgurate with high-frequency current if neces-
sary.
Sweating Feet. This condition is a great source of
danger to the soldier. Daily cold water baths should be
used. Rub with 10 per cent salicylic acid in alcohol.
Dry and apply 1-1000 potassium permanganate, 10 per
cent formalin, or 25 per cent aluminum chloride. The
sock may be dipped in 1-2000 bichloride and dried. Treat
daily with foot liniment.
Chilblains. In mild cases stimulate by friction, foot
liniment and frequent changes of dry woolen socks. The
severe cases demand only cold applications, rest and ele-
vation. No massage or heat should be used.
Trench Foot. The phenomenon is similar to the effect
of frost-bite and was formerly common. When proper
precautions are taken it is largely preventable at the
present time. The cause is cold, wet and interference
with the circulation. The onset is gradual, characterized
FOOT STRAIN 227
by chilling and numbness. There is no pain at first.
Later on swelling of the feet and marked pain develop
where the blood still circulates sluggishly just above the
affected area. Treatment is aimed largely at prevention
by cleanliness, oiling and several pairs of clean dry
socks, with the outer coverings of the foot and leg loosely
applied. It was aimed to keep the trenches as dry as
possible, the feet and toes in constant motion, and not to
allow the shrinking of wet leggins to constrict the leg.
Foot coverings were removed, dried with hot pebbles or
oats, the feet rubbed and again covered. Warm drinks
and dry garments are factors of importance in preven-
tion. Treat by elevation with exposure to sun and air.
Electric light baths followed by massage when the
oedema lessens. Aspirate bullae if present, and give anti-
tetanic serum if the feet have been abraded. Morphine
is indicated where the pain is severe.
Shoe Fitting. No study of foot ailments is complete
without a consideration of that greatest of all factors in
their avoidance, namely, proper shoes.
The Munson last with its straight inner line and broad
toe provides the best shoe for men. In the Army the
recruit is fitted as follows : He stands on the rule on his
left foot, with forty pounds on his back. His foot length
is then determined and he is given the second larger size.
The width is determined by a scale from the circumfer-
ence of the fore foot at its broadest part. After six
months his strengthened foot muscles require refitting of
his shoes.
When the shoe is on and his weight all on the left foot,
228
ORTHOPEDICS
PRESCRIPTIONS
Com Collodion
Salicylic Acid 11 parts
Ext. Cannabis In-
dica 2 parts
Alcohol. 95 per cent. 10 parts
Flexible Col-
lodion ad 100 parts
Stimulating Limment
Chloroform 1 part
Spirits of Tur-
pentine 31/2 parts
Olive Oil 31/2 parts
Oily Liniment for Sweating
Methyl Salicylate
or Oil Wintergreen. . . 2 oz.
Carbolic Acid 1 dr.
Camphor,
Chloral,
Menthol aa 2 dr.
Spirits of Turpentine . . 4 dr.
Alberine Oil q.s. ad 8 oz.
Com Sc^ve
Salicylic Acid 40 parts
Vaseline 30 parts
Lanolin 30 parts
Aqueous Liniment for
Sweating
Salicylic Acid 3 dr.
Camphor,
Carbolic Acid aa 30 gr.
Dissolve in Alcohol 95
per cent., add 3 oz.
Glycerine 1 oz.
Ext. Hamamelis 4 oz.
Alum, pulv 4 dr.
Aquae q.s. ad 12 oz.
there should be spare length of about the breadth of the
forefinger in front of the longest toe. The leather over
the dorsum should just wrinkle but not enough to be
grasped by the fingers.
Chapter XTV
BEACES AND CASTS
Braces. A good generalization on the theory of the
treatment of orthopedic defects by braces is hard to find
in the literature. The descriptions of use of different
types of braces in the various deformities are scattered
throughout the text books, and the application of the
same general principles in each case is often obscure.
This failure to grasp the fundamental principles has been
evident in some of our army orthopedic instruction as is
stated by Major R. W. Lovett, of Boston. He says:
''The student as a rule is taught that a certain splint is
used for tuberculosis of the hip, another for Pottos dis-
ease, another for club foot and a fourth for flat foot. He
does not connect these, nor does he understand their prin-
ciples very well, and as a rule speedily forgets all about
them except, perhaps, the name. It has been found pos-
sible to get some knowledge, apparently more permanent,
into the minds of the students by a different method of
approach. It is taught that apparatus may be of wood,
plaster, iron, tin, leather and other materials; that
crutches are apparatus and so are ham splints ; that ap-
paratus should be used for a definite mechanical purpose,
and that if the student does not understand what he is
trying to do, he will probably not fit satisfactory braces ;
229
230 ORTHOPEDICS
that apparatus is used for four purposes: (1) fixation,
(2) traction, (3) support or protection, and (4) correction
of deformity. A case is shown, its pathology analyzed,
and its mechanical needs, if any, are formulated. It may
require the application of one of the four purposes de-
scribed above, and if so the student is required to work
out the mechanical needs without calling apparatus by
name. He is asked to work out in wire or paper or on the
blackboard the theory of the required apparatus. He is
then requested to state practically how it could be done in
plaster, leather or metal, and he is then made familar
with the accepted splint to meet that need. The response
of students to this method of instruction has in this de*
p^rtment been most satisfactory. ' ' *
The same broad treatment of the question of braces
and splints was being taught by Major E. S. Geist, M. C,
U. S. A., at Camp Greenleaf . A set of simple tools, which
he has devised and called the ** Oglethorpe Kit," with
bench and vise, was sufficient for the improvisation of
many splints from wire, which he found to be a most use-
ful material. For the heavier braces a blacksmith's tools
are necessary. Provision for lengthening each type of
the various braces here described should always be made,
except in the case of adults.
Arch braces are described under the topic of flat foot.
Talipes Calcaneus. This brace consists of two lateral
bars curved forward to about an angle of 130 degrees at
the external malleolus, joined in front and below by a thin
* A System of Orthopedic Instruction, American Journal of Orthopedic
Surgery, August, 1918, page 487.
BRACES AND CASTS 231
eole plate and above by a leather cuff. Complicated by
valgus or varus, the deformity is checked by a plate under
the sole and over the edge of the foot.
Knee. For arthritis, or ligament strain about the knee
joint, the best brace is a simple hinge, locked against over-
extension and supported by a broad leather cuff on th^
tipper curve of the calf and lower half of the thigh.
For tubercular knee, the best brace is the Thomas
splint, consisting of two side bars extending below the
shoe and joined by a cross bar, which acts as a stilt. It is
joined together above by a padded ring, which fits snugly
at the upper part of the thigh, this ring so inclined that
the weight is evenly distributed. Certain common modi-
fications allow for active extension of the knee by means
of moleskin plaster and buckles and various other me-
chanical means.
The caliper splint of Ridlon and Jones is used in the
recovery stage, and is so arranged that a gradually in-
creasing amount of weight can be borne upon the foot.
The bow-leg brace consists of a strong inside column
and, occasionally, a lighter external one with cross bar
through the heel of the shoe. There is a hinge at the
ankle joint and a posterior band above, curved obliquely
upward and outward to the great trochanter. A short,
hinged, vertical piece from this point is connected with a
waist strap. Two broad cuffs on the thigh and calf exert
traction toward the strong inner bar. There is a modifi-
cation of this long brace by Napier and a short Knight
bow-leg brace.
The knock-knee brace of the Thomas and other types
232 ORTHOPEDICS
are very similar, with the strong supporting column
hinged at ankle and hip on the outer side. There is not
usually an inner support.
Leg. Infantile leg braces are similar to the last two
types described with the exception that they have two
firm lateral supports usually hinged at the hip and at the
knee, with a lock which the patient may manipulate. A
hinge at the ankle is locked against extension, and an
arch plate fits inside the shoe.
Bach. Back braces, for use largely in tuberculous
spine, consist of two strong bands of steel shaped to the
contour of the spine from the bony pelvis to the neck, with
a semi-circular steel hip band and a front canvas apron,
cut to fit the chest and abdomen firmly. A head support
by means of a ring around the chin or a jury-mast over
the head with a sling is indicated where surgical lesions
are present.
Casts. Plaster-of-Paris as a means for securing well
fitted support, protection and extension, is worthy of a
wider use in general practice than it has yet attained. Its
ease of application, quick setting and the convenience
with which it can be carried are greatly in its favor.
Plaster bandages are easily prepared at home by cut-
ting long strips of coarse muslin or crinoline to the de-
sired width of two, four, or six inches. White plaster is
best, but gray, coarse plaster is serviceable. It should be
rubbed thoroughly into the meshes of the cloth, which is
tightly rolled as you go along, and then kept in a moisture
proof metal or glass container. "Wide bandages when well
rolled are easily cut by a plaster knife.
BRACES AND CASTS 233
It is impossible to avoid some spreading of the plaster
in rapid work, so the clothing and floor should be prop-
erly protected. The skin should be cleansed with warm
water and soap, or alcohol, dried and then powdered.
Any abraded surface should be covered with sterile gauze
and later a window cut through the cast at that point.
The part to be incased should be wrapped in some soft
material, cotton roller bandage, a thin layer of cotton,
jersey or other material. A felt jacket may be used for
the body. Joints and points of pressure need extra
padding. Crushed tissue paper or even newspaper is of
service here. The bandage is then immersed in warm
water for twenty or thirty seconds or until bubbling has
ceased, when it should be picked up with the open ends
against the palms of the hands, and excess of water
gently squeezed out. This hold prevents undue loss of
plaster. The surgeon should protect his hands if possi-
ble, with cheap rubber gloves. If this is not possible pro-
tect the under side of the nails by filling them with soap
or cold cream. Plaster is easily removed by the use of
a little sugar or com meal.
The part is held in the desired position by an assistant
until after setting is fairly complete, the bandages being
applied in the same manner as in simple bandaging. It is
often desirable to increase the rigidity of the cast by
rubbing in dry plaster scattered over the surface during
the application. Another means of strengthening a weak
point is by doubling the bandage back and forth and over-
laying it again with circular strips.
In club foot and several other conditions there is
234 ORTHOPEDICS
plenty of time to secure the correction after the cast has
been applied, maintaining it during setting. With an in-
delible pencil, while the cast is still wet, the upper and
lower edges and any desired windows can be marked and
then cut. Some surgeons insert at the beginning a sheet
of tin or other substance upon which to cut down when the
time comes for removal. With care and a little skill in
cutting this is usually unnecessary. Two vertical and
parallel cuts a quarter of an inch apart, with the free use
of vinegar, in an old cast make removal fairly easy. All
wounds are dressed through sufficiently large windows.
The extremities, toes and finger tips should, when pos-
sible, be exposed as a guide to the condition of the cir-
culation under the cast. X-rays are usually more read-
able through casts than through many of the common
prepared splints. See that the edges are rounded and
well padded in such places as, for instance, the axilla.
GLOSSARY
TISSUl! ; NAMa PERTAININQ TO
arthral joint
cardiac heart
carpal . wrist
colonic large intestine
enteric ....... small intestine
gastric . stomach
genu knee
hallux great toe
hemal, hsemal hlood
jnyo muscle
nephric kidney
neural nerve
osteo bone
pedal fooi
synovial membrane (joint)
talipes foot deformity
tarsal ankle
teno-synovial membrane (tendon)
POSITIONS
abduction owO'V from the body
adduction toward body
calcaneus ^^ ivalking
equinous *o viking
epi
supra
. above
235
236 OETHOPEDIOS
"below
infra
sub
end endo inner
peri outer
prone /oice or pcdm down
supine face or palm up
'I ... aiway from center of body
peripheral J
proximal toward center of body
cervical neck vertebrce seven
I chest vertebrcB twelve
dorsal j
lumbar abdominal vertebrce five
valgus turned in
varus turned out
SUFFIXES
algia . ,' pojln
eetomy to cut out
itis inflammation, of
osteomy to leave opening into
otomy to cut into
SPINE
kyphosis increased dorsal curve
lordosis increased lumbar curve
scoliosis rotary lateral curve
torticollis ...... urry neck
INDEX
Abbott jacket, 129
Abrasion on feet, 225
Abscess, bone, 149
Acromioclavicixlar joint, dislocation
of, 153
Acromion process, fractures of, 154
Adhesions, after treatment, 139
breaking down, 70
Ankle, after treatment, 203
complications, 203
dislocations, 203
fractures, 202
Pott's, 202
sprains, 139
strains, 139
Ankylosis, best position in ankle,
202
elbow, 174
hip, 192
knee, 198
shoulder, 165
Apparatus, gymnastic, 19
occupational therapy, 82, 85
physiotherapy, 25, 30
Arm, exercises, infantile, 98, 99,
100
general, 19
joint mobilization, 20
Arch, anterior, 216
exercises for, 216
hammock, 215
steel, 212
Arthritis, acute rheumatic, 142
atrophic, 141
deformans, 140
degenerative, 140
gonorrheal, 144
hypertrophic, 141
osteoarthritis, 143
proliferative, 140
rheumatoid, 140
' spondylitis, 140
syphilitic, 144
toxic, 140
traumatic, 139
tubercular, 142
Articular cartilages, 135, 197
Articular injuries, 135
operation, 136
treatment, 136
Astragalus fractures, 203
dislocations, 203
Back, massage of, 53
Baking, physiological effects, 27
technique, 28
Bandaging, 233
Baths, cabinet, 30
contrast, 34
electric, 30
whirlpool, 34
Bone, diseases of, 146
osteitis, 149
osteomalacia, 150
osteomyelitis, 149
periostitis, 146
repair in, 146
rickets, 92
tuberculosis, 151
Bow-legs, 231
Braces, 229
Brachial plexus, 104
injuries to, 104
Bradford frame, 181
Bunion, 220
Bursitis, 71
Callosities, 226
Cartilage {See Articular), 135, 147
Cell, galvanic, 39
Chilblains, 226
Circumflex nerve paralysis, 104
Club-foot, 91
Contracture, 14
Corns, 225
Coxa vara, 92
Deltoid-paralysis, 104
Diathermy, 44
Dislocation, acromioclavicular, 153
ankle, 203
elbow, 170
hip, 186
237
238
INDEX
Dislocation, knee, 197
shoulder, 157
vertebrae, 110
wrist, 178
Douche, Scottish, 34
Drop-foot, 105
Drop-wrist, 103
Effleurage, technique, 54
uses, 57
Elbow, adhesions, 169
ankylosis, 173
dislocations, 170
fractures about, 169
Exercise, arch, 216
athletic training, 4
fatigue in, 2
relation to age, 9
relation to sex, 8
safeguards, 4
settiQg-up drill, 17, 18
spinal curvature, 117, 118
types, 9
endurance, 9
skill, 9
speed, 9
strength, 9
Faradism, 40
Fatigue, 10
Femur, fractures of lower third,
194
middle third, 193
upper third, 192
Fibula, fractures of lower third,
202
middle third, 201
upper third, 198
Fixation, plaster, 222
splints, 230
Foot, anterior metatarsalgia, 216
deformities of, 219
flat-foot, 205
acute strain, 223
chronic strain, 223
flaccid flat, 221
plates for, 212
rigid, 222
shoes, modifications of, 224
spastic, 222
Fractures, after treatment, 69
carpus, 178
clavicle, 152
Colles, 177
complications, 149
femur, 192
Fractures, fibula, 202
foot, 204
hand, 178
humerus, 161
olecranon, 169
patella, 195
Pott's, 202
radius, 177
scapula, 153
semilunar, 197
spine, 110
tarsus, 203
tibia, 198
ulna, 177
Frame, abduction, 184
Bradford, 181
suspension, 181
Friction, 61
Galvanism, 39
Graft, bone, 108
Gymnastics, medical, 10
re-educational, 99
Hallux rigidus; operations for, 223
valgus, 222
Hammer toe, 223
Health, dependence on muscle func-
tion, 1
Heart, exercises, 7
High frequency, 43
Hibbs' table, 192
Hip, abduction, splint for, 184
ankylosis, position for, 186
braces, 232
coxa vara, 93
dislocations of, 186
fractures of, 191
Hydrotherapy, physiological effect
of, 29
technique, 33
types of baths, 34
Hyperaemia, active, 27
passive (Bier's), 28
Ionization, 40
Ischemic paralysis, 177
Joints, ankylosis, positions for, 202
flail, 136
injuries to, 135
' massage of, 139
mobilization of, 138
Knee, adhesions, 195
ankylosis, 19^
INDEX
239
Knee, bursitis, 71
dislocations, 197
fractures about, 195, 197
internal injuries, 197
rupture of crucial ligaments, 198
semilunar cartilages, 197
synovitis, 69
Knock-knees, 92
Kjphosii, exercises, 117, 118
Leg, exercises, 101
Ligaments, injuries, 136 ,
treatment, 138 >
Lordosis, exercises, 120, 121
Massage, contraindications, 63
indications, 54
technique, 54-62
types, 46
Mechanotherapy, 131
Median nerve, 104
Metatarsalgia, 216
Mirror, use in exercise, 114
Movements, passive, assistive, aetire,
resistive, 13
Muscle atrophy, 103, 104
balance, 14
contracture, 14
degeneration, 177
electrical stimulation, 39
fatigue, 17
massage, 57
tonus, 14
Musculocutaneous, 104
Musculospiral, 104
Nauheim exercises, 10
Nerve injuries, central, 93
peripheral, 103, 104
scarg, adherent to, 105
Occupational therapy, 79
Osteitis, 149
Osteogenesis, 150
Osteomalacia, 150
Pain, massage, guide, 49
passive movement, guide, 13
scars, 62
Paralysis, flaccid, 97, 103
infantile, 97
spastic, 93
traumatic, 104
Passive movements, 13
Peronei, transplantation of, 103
Petrissage, 57
Phalanges, dislocation, 178, 204
fractures, 178, 204
Physiotherapy, 27
Plaster of paris, application, 232, 233
preparation, 233
Popliteal nerve, paralysis of, 104
Pott's disease, 107
Prescriptions, foot ailments, 228
Pulley weights, exercises, 17-24
Badiant heat, 27
Reconstruction, 10
Ee-education, 97
muscle, 10
physical, 17, 222
vocational, 79
Bheumatism, 140
Eickets, 92
Sacroiliac lesions, 112
strapping, 112
Scar tissue, contractures, 62
massage, 61
pain in, 62
stretching of, 13
Scoliosis, braces, 129
diagnosis, 127
exercise programs, 130
prognosis, 130
types, 123
Septic wounds, Carrel-Dakin, 150
massage, 57
violet ray, 44
Shoe, fitting, 227
modifications of for foot deform-
ities, 224
Shoulder, ankylosis, position for,
165
dislocations, 157
exercises for deformities, 18
fractures about, 162
Sinusoidal current, 43
Spine, arthritis, 140
braces, 232
casts, 232
dislocations, 110
fractures, 110
kyphosis, 113
lordosis, 119
torticollis, 110
tuberculosis of, 107
Splints {See also Braces), caliper,
192, 231
humeral extension, 166
Jones' cockup, 105
240
INDEX
Splints, Thomas leg, 231
wire cockup, 103
Sprains, diagnosis, 137
treatment, 138
Static electricity, 44
Strapping, back, 112
flat foot, 211
metatarsalgia, 216
sprains, 138
Stumps, massage of, 75
preparation for prothesis, 76
Sun lamp, 44
Synovitis, treatment of, 69, 224
Tapotement, contraindications, 58
technique, 61
Tarsus, injuries to, 203
treatment of, 203
Tendons, massage of, 68
tenoplasty, 222
tenosynovitis, 69
tenotomy, 222
transplantation, 103
Thermolight, 27
Thermaphore, 27
Thomas heel, 224
Thomas splint, arm, 161
leg, 231
Tibial nerve, paralysis of, anterior,
105
posterior, 105
Trench foot, 226
Tuberculosis {See Arthritis and
Bone), 142, 151
Ulnar nerve, paralysi* of, 104
Varicose veins, massage of, 64
Vertebrae (See Spine), 106
Vibration, manual, 61
mechanical, 61
Vocational reconstruction, 106
Volkmann's contracture, 177
Whirlpool bath, 34
Whitman arch plate, 215
Wrist, drop, 103
exercises for, 103
injuries, 177
treatment, 177
Paul B. Hoeber, 67-71 East 69th Street, New York
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