ciently to be up and around with but a slight limp. The same condition could have been caused if the head of the femur had been dislocated, and marked pressure made at the points of fracture by attempts toward reduction, driving a bony fragment through the vaginal wall.

I invariably watch for acidosis in these cases, and undertake to combat it by early administration of large doses of sodium bicarbonate and by reducing the amount of protein in the diet, as these patients are already taking up about all the protein matter that they can handle by absorption, as is easily discovered by the relation of the degree of temperature to the pulse-rate, and their nitrogen ratio. I find that they run a less stormy course by this.method 'than was formerly seen when so little attention was given to this particular phase of the treatment.

VOLKMANN'S CONTRACTURE

E. M. SANDERS, M.D.

NASHVILLE, TENNESSEE

One of the most serious complications that can arise in the treatment of fractures and other injuries of the extremities is a Volkmann's contracture. This unforseen deformity usually presents itself to the surgeon as a great surprise, and to the patient as a greater disappointment. When the case is well developed before recognized, the treatment requires great patience, good judgment, and unusual skill on the part of the surgeon, and a mental attitude of faith and perseverance on the part of the patient.

Since the illustrious Volkmann described this condition, in 1869, and gave us the definite clinical picture of claw-hand, or "main-en-griffe," a few observers, including Lesser, Thomas, Sayre, Murphy, and others, have given the subject earnest thought and investigation; but the profession as a whole has paid very little attention to this most interesting condition, inasmuch as it is not a common occurrence. After careful investigation, I am led to believe that it happens more frequently than the impression one gets from the literature.

Inasmuch as the condition is usually due to bad initial management of the injury, few of us are inclined to report and discuss our cases, or those of our confreres, with the same freedom that we would discuss other complications of equal seriousness and coming about through unavoidable means. Doubt

less, there are many cases not reported, and some are diagnosed as other conditions.

Definition. In the ordinary acceptation of the term, "Volkmann's contracture" means a permanent longitudinal contracture of the flexor muscles and tendons of the forearm, usually accompanied by more or less fixation of these muscles to each other and to the surrounding tissues, frequently complicated by a permanent shortening of the anterior capsule of the wristjoint. However, a similar condition of other muscles may occur. The biceps has undergone this degeneration, the flexor muscles of the leg, and, in fact, the flexor muscles of all four limbs on the same patient at the same time, caused by the application of four tourniquets simultaneously used with the hope of saving the patient's blood during an alarming hemorrhage from the uterus.

The volar surface is practically always involved, and the extensors are seldom interfered with, although the pressure is equal all around the arm.

The flexors of the thumb are seldom affected, probably on account of their extensive origin and the great length of the body of the muscle, although we have had one case in which we used the prophylaxis where the thumb was more deformed than any of the fingers, due, we believe, to our failure to reach and relieve the tension in this deep region.

Frequency. The records show that Volkmann's contracture occurs most frequently in children from one to fourteen years of age, and usually follows fractures about the elbow and upper forearm, coming, as a rule, in those cases where the arm has been put up in the flexed position and dressings applied under anesthesia immediately after the injury.

Just why the condition is more frequent in the flexor group of the forearm than in other groups of

muscles is not definitely settled, but it is believed by some observers that this is due to two facts:

First-The region is more bountifully supplied with blood, the return flow of which when interfered with brings about a greater congestion of the tissues with the same amount of interference than in other parts.

Second-These groups of muscles are bound around with strong fascial sheaths, which prevent dilatation and relief of the congestion.

The condition is much more frequent in children than in adults. This may be due to the fact that their muscles are more delicate and immatured, and, therefore, more easily destroyed; but many observers believe that children are made to suffer greater pain after the reduction of fractures and the application of splints than adults, who under like circumstances insist on the dressing being loosened or removed, and consequently the threatened condition is often prevented.

A fracture which has been properly reduced and had a suitable dressing applied should not be a painful condition, except in extraordinary cases.

Etiology. The etiology is by far the most important element of the subject; and the fact that such a small percentage of those who have fractures about the elbow and upper forearm badly treated develop this lesion, might suggest the possibility of a fundamental deficiency in the nutrition of the muscles of those in whom is does appear.

The condition can be brought about in two distinct

cases:

1. In cases where splints, dressings, bandages, or tourniquets are applied too tightly and allowed to remain too long; or where they are applied properly and subsequently the injured member swells and produces a condition of ischemia.